Membership Application
Pikes Peak Radio Amateur Association, Inc.
P.O. Box 16521, Colorado Springs, Colorado 80935

Date: _______________________________________ [_] New Membership [_] Renewal

Name: _____________________________________________________________________________________________

Address: ___________________________________________________________________________________________

City: _________________________________________________________State: ___________Zip: __________________

Call: _____________________License Class:_____________ _________Telephone: _______________________________

Additional Name:_____________Call___________Class________ ARRL mbr? [_] Yes [_] No

Additional Name:_____________Call___________Class________ ARRL mbr? [_] Yes [_] No

Additional Name:_____________Call___________Class________ ARRL mbr? [_] Yes [_] No

E-mail address:_________________________________________________________

Do you want your newsletter delivered via e-mail in PDF Format?________ [_] Yes [_] No

Are you an ARRL member? [_] Yes [_] No

One year membership rates, prorated, January through December:
(See schedule at bottom)
[_] Full Member - $15.00
[_] Full Member over 65 - $10.00
[_] Associate Member - $12.00 		[_] Family Membership (same address) - $18.00
[_] Family Membership (both over 65) - $12.00
[_] Newsletter only $12.00

Please check activities for which you would volunteer:

[_] Field Day [_] Hamfest
[_] RFI Committee [_] Radio demonstrations
[_] On-Air Nets/Roundtables [_] Teach potential hams about ham radio (Elmering)
[_] Special Event Communications (walks, foot races, bicycle races, etc.)
[_] Hospitality [_] Public Relations

Your Interests:
[_] HF [_] VHF/UHF [_] Contests [_] Technical [_] FM [_] SSB [_] Pub Svc/Emergency Comm
[_] Digital [_] DX [_] Hardware [_] ________ [_] ________ [_] ________

  Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full: $15.00 $13.75 $12.50 $11.25 $10.00 $8.75 $7.50 $6.25 $5.00 $3.75 $2.50 $1.25
Family: $18.00 $16.50 $15.00 $13.50 $12.00 $10.50 $9.00 $7.50 $6.00 $4.50 $3.00 $1.50
Senior: $10.00 $9.17 $8.33 $7.50 $6.67 $5.83 $5.00 $4.17 $3.33 $2.50 $1.67 $0.83
Sr Fam: $12.00 $11.00 $10.00 $9.00 $8.00 $7.00 $6.00 $5.00 $4.00 $3.00 $2.00 $1.00
Associate: $12.00 $11.00 $10.00 $9.00 $8.00 $7.00 $6.00 $5.00 $4.00 $3.00 $2.00 $1.00

Please Note: You must submit a completed application form along with your check to the Treasurer for both new members as well as renewals. Thank you. PLEASE TYPE OR PRINT CLEARLY!