SOUTHEAST LOUISIANA AMATEUR RADIO CLUB, INC. MEMBERSHIP APPLICATION/RENEWAL (SUBMIT THIS APPLICATION FORM & DUES TO: SELARC, P.O. Box 1324, Hammond, LA 70404) NAME__________________________________________CALLSIGN_______________ ADDRESS______________________________________________________________ CITY_________________________________STATE_______ZIP_________________ PHONE #_______________________________BIRTHDATE______________________ SPOUSE'S NAME_____________________EMAIL ADDRESS _____________________ DATE FIRST LICENSED______________________ EXPIRES____________________ LICENSE CLASS_____________________ ARRL MEMBERSHIP #_________________ TEN-X MEMBERSHIP#__________________ QCWA MEMBERSHIP #________________ ARES MEMBER YES / NO (CIRCLE ONE) ARRL / W5YI VE#__________________ DUES: $30.00 REGULAR AND ASSOCIATE MEMBER $25.00 REGULAR AND ASSOCIATE MEMBER (OVER AGE 62) $17.50 REGULAR AND ASSOCIATE MEMBER (UNDER AGE 17) $10.00 EACH ADDITIONAL LICENSED MEMBER LIVING AT THE SAME ADDRESS - SUBMIT SEPARATE FORM FOR EACH IN SUBMITTING THIS APPLICATION FOR MEMBERSHIP TO THE SOUTHEAST LOUISIANA AMATEUR RADIO CLUB INC. (SELARC), I DO HEREBY AGREE TO ABIDE BY THE CONSTITUTION AND BY-LAWS OF SAID ORGANIZATION AND AGREE TO COMPLY WITH ALL RULES AND REGULATIONS PERTINENT TO THE AMATEUR RADIO SERVICE (FCC PART 97). SIGNATURE (REQUIRED)_____________________________ DATE__________