THE LAKE ERIE AMATEUR RADIO ASSOCIATION
MEMBERSHIP APPLICATION

Callsign:

  

First Name:

  

Last Name:

  

Mailing Address:

  

Additional Address (opt):

  

City:

  

State:

  

ZIP+4:

  

Area code + Phone #:

  

May we publish phone #?:

 (circle one)   YES    NO

FCC License Grade:

  

License Expiration Date:

  

Membership Type:

 (circle one) REGULAR Other:

Family Member info:

 see below* 

ARRL Member Info:

 (circle one) NO LIFE  ANNUAL   Member #:

E-Mail Address (opt):

  

Occupation (opt):

  

I hereby certify that I hold a valid amateur license and will observe
the Bylaws and Repeater Users' Guide of the Association if elected to
membership.
SIGNATURE:.................................... DATE:..../..../......
(Attach a copy of your license or show it to an active LEARA member and ask him/her to sign below.)
VERIFYING MEMBER'S SIGNATURE:........................... DATE:..../..../......
VERIFYING MEMBER'S PRINTED NAME:........................ CALLSIGN:............

! ! ! PLEASE NOTE ! ! !
Annual dues: $25/year or $2.25/month from date of application through December.
MAKE CHECK PAYABLE TO LEARA. Put your callsign on the check.

First name as desired to appear on
your complimentary LEARA membership badge:..................
*Licensed members of your immediate family, living at the above address, share in your membership. List below and they will receive complimentary badges.

NAME:........... CALL:......       NAME:........... CALL:......    NAME:........... CALL:......

Mail application and dues to:     L E A R A    PO BOX 22823    BEACHWOOD OH  44122-0823

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
- FOR OFFICE USE ONLY -
Dues $....... Rec'd by:...........Date:..../..../.... Data Base update....../..../....
Welcome Ltr......../.../... Badge Ordered........./.../... Badge mailed......./.../...
Notes:.....................................................................................
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