METRO DX CLUB W9TY

www.metrodxclub.com

MEMBERSHIP REQUEST

(PLEASE PRINT)   DATE_________________________

Name: ____________________________________________ Call: ____________________

Address: ______________________________________ License class: ___________________

City: ____________________________________ State : ______ Zip: ____________________

Phone: _____________________ E-Mail: _________________________________________

ARRL Member?  Yes______ No______   Use LoTW? Yes _____ No ______

Number of DXCC Countries Worked___________ Confirmed_____________

Amateur awards received: ___________________________________________________________________

Other Amateur Radio clubs you belong to:

________________________________________________________________________________________

Occupation: ________________________________________________________________

Main Interests for club activities are:

DXpeditions: _______ Field Day: ________ Contest operating: _______

Im willing to serve as an officer or on club committees: YES ____ NO _______

Other interesting info: _________________________________________________________________

My other hobbies are: _______________________________________________________

Please complete and mail to:  METRO DX CLUB, 3810 N. Chamlin Drive , Morris , IL 60450 USA

or complete and email to: w9ty@arrl.net

You will be contacted with information regarding your requested membership and US$15.00 annual dues.