Name:
Call Sign:
License Class:	Technician Technician w/HF General Advanced Extra
Street Address:
City:
County:	Dodge Fillmore Freeborn Goodhue Houston Mower Olmsted Rice Steele Wabasha Winona
State:	Minnesota
Zip Code:
Email Address:
Web Page URL:
Home Phone:

Ham radio interests:

ARRL Member:Yes No

Membership type (select one):

Individual Membership
Annual dues $25.00. If joining during 2Q, $20.00. If joining during 3Q, $15.00.
If joining during 4Q, the full annual dues amount includes 4Q of current year plus all of following year.

Family Membership
Annual dues $35.00. If joining during 2Q, $30.00. If joining during 3Q, $25.00.
If joining during 4Q, the full annual dues amount includes 4Q of current year plus all of following year.

List family members:

Name	Call	ARRL Member	Email
		Yes No
		Yes No

Student Membership
Annual dues $20.00. If joining during 2Q, $15.00. If joining during 3Q, $10.00.
If joining during 4Q, the full annual dues amount includes 4Q of current year plus all of following year.