APPLICATION
W2LIS | www.w2lis.com | w2lis@aol.com
575 Long Island Amateur Radio Club
14 IVY Road, Mastic Beach, NY 11951
Membership Application
Please put your callsign on the check (made out to LIARS) and complete below:
Dues are $30 individual, $35 family
Name:__________________________________________Callsign:__________
Address:_________________________________________________________
City:____________________________________State:_______Zip:__________
Phone #:______________________________ Publish in Roster? Yes[ ] No[ ]
e-mail address:_________________________ Publish in Roster? Yes[ ] No[ ]
License: [ ]Novice [ ]Tech [ ]Tech+ [ ]General [ ]Advanced [ ]Extra
ARRL Member: Yes[ ] No[ ]
[ ]Check to receive the Roster by e-mail-Valid e-mail address required
********************************************************************************************
Second member info (living in same household)
Name:__________________________________________Callsign:__________
Phone #:______________________________ Publish in Roster? Yes[ ] No[ ]
e-mail address:_________________________ Publish in Roster? Yes[ ] No[ ]
License: [ ]Novice [ ]Tech [ ]Tech+ [ ]General [ ]Advanced [ ]Extra
ARRL Member: Yes[ ] No[ ]
[ ]Check to receive the Roster by e-mail-Valid e-mail address required
Amount Enclosed (there is room here to send in dues for two people)
Membership Dues expire December 31st of the current year
Total Enclosed: $_______________
If paying for more than 2 in your home, Please use an additional sheet.
I respectfully request that this application be considered by
the Officers and Directors of LIARS.
Date:___________ Signature:______________________________________________
[ ] Please check here if any info on this form has changed from last year
Dues expire December 31st of the current year
SEND APPLICATION via email to : w2lis@aol.com
or mail to :
575 Long Island Amateur Radio Club
14 IVY Road, Mastic Beach, NY 11951
Or you can submit an online Application right here by using the form below and mailing in your check.
