WWAMA

Application for Membership in the Wattsburg Wireless Association

Name:________________________________________________________________

Address: ____________________________________________________________

City:______________________ State:_________________ Zip _____________

HOME PHONE: ___________________ cell PHONE: __________________

E-MAIL ADDRESS: ___________________________________________________

Current Call sign:_________________ ARRL Member: Yes NO

VE Certified : Yes No Arrl certified instructor: Yes No

Current Club affiliations: ____________________________________________________

Birth date: MO___ Day____

We do not discriminate because of age

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Type of membership desired (check one please)

Active full member (Must be Ham Licensed or become licensed within 6 months of joining) (dues $15/year)

Active Associate Member (non-voting) (Dues $10/year)

Youth Member (must be under 16 years of age) (dues free, donations accepted)

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Note: Contact the treasurer or President at any meeting to pay dues. I understand if I am required to pay dues, failure to pay dues for 2 months will suspend my membership until said dues are paid in full.

Signature:_________________________________ Date:___________________

You may email this to WWA@WATTSBURG-WIRELESS.US or mail to Wattsburg Wireless 9333 Tate Rd Rm 107 Erie PA 16509

Do not write below this line

Accepted Yes No Date Accepted/Rejected _____________________ Signature of Association Officer and Office

________________________

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