SOUTHEASTERN DX CLUB MEMBERSHIP APPLICATION
207 Longview Dr Norcross GA 30071-2127
Membership type (self/family/student - see below): ______________
Date ______________________
Name:____________________________________ Callsign:___________
Class: __________
Spouse: _______________________________ Spouse Callsign:____________ Class:__________
Address:_____________________________________________________________________________
City, State, Zip: ___________________________________________________________________
Home Phone: ____________________ Work Phone: ______________________ Ext:______
Fax Phone: __________________________
E-Mail:_______________________________________________
ARRL Member (Y/N):______ ARRL Life Member (Y/N): ________
Previous Callsigns:_______________________________________________________________
Awards:
DXCC (Y/N): _______ Mixed: _______ CW: _______ Phone: _______
RTTY: _______ WAS _________
5BDXCC: _______ 5BWAS: _______ 5BWAC:
_______ HONOR ROLL: _______
OTHER: _________________________________________________________
Interests: DX: ________ Phone: ________ CW:________VHF/UHF:________RTTY: ________
AWARDS:________CONTESTING:________DXPEDITIONS:________FIELD DAY:________
OTHER:_______________________________________________________________
| Dues structure: | New individual member dues (General/Adv/Extra): | $12.00 |
| New family dues: | $25.00 | |
| Student dues (bulletin by email only): | $5.00 | |
| New member(Novice/Technician) dues: | $5.00 | |
| Regular Renewal dues: | $20.00 | |
| Student Renewal dues: | $5.00 |
Donations: Packet Cluster __________ Other _______________________________________________
Make your check payable to SEDXC and send to:
Southeastern DX Club
c/o Mike Weathers ND4V
207 Longview Dr
Norcross Georgia 30071-2127
SEDXC Membership Application Rev. 03/10/2007