Given Name: (print) ……………………….……… Family Name: (print) ………..……………………...

Residential Address: ………………………………………………………….. Postcode: ………….

Postal Address: …………………………………………………………….….. Postcode: ………….

Call Sign: ………………………… Date of Birth: …. /…. /….

Email Address: ………………………………………………..…………………………………………

Phone: (hm) ……………………… (wk) ………………………. (mob) …………………………….

Occupation: …………………………………… Skills/Interests: ……….…………………………

Amateur Radio Interests: (circle) HF VHF UHF ATV SSTV PACKET Morse

Contest Education DX Other: ……………………………………………..…..

WIA member: Y / N ($1.00 Ins. Levy applies for non-members of WIA) WICEN member: Y / N

LADARC Membership required: (circle) Full $20 / Pensioner $10 / Associate $10 (non licensed)

I hereby wish to apply for membership to the Liverpool and District Amateur Radio Club and agree to be bound by the terms of the Constitution and by-laws of the Club and future amendments. I understand that my membership is subject to committee approval and I am aware that the activities of LADARC involve the use of electricity and electrical equipment, and that there are dangers inherent in the use of such equipment and accessories, therefore I absolve the club from any liability arising thereof.

Applicant: (signed) ………………………………………………..

.

1^st Proposer: (name) ……………………… (signed) …………………………. Call Sign: ……………….

2^nd Proposer: (name) ……………………… (signed) …………………………. Call Sign: ……………….

Fee paid $: ………..… (Includes WIA levy) Date: …. /…. /…. Receipt No: …………………….

--------------------------------------------- Committee to complete ---------------------------------------------

Accepted on: …. /…. /…. Membership No.: ………… Secretary: (signed) ………………………….

………………………………...return this bottom section to member once approved………………………………

LADARC Information Brief

Welcome ……………………………. as a (Full / Pensioner / Associate) member of L.A.D.A.R.C.

Date accepted: ….. /….. /….. Membership No.: ………………

Club meetings: 2^nd Wed. of the Month - 8.00pm start

Club Web site: www.suburbia.com.au/~colinc/ladarc/ladarc.htm
Secretary Contact: Garry - (hm) 0298965763 email: vk2tsr@bigpond.com

Mail to: LADARC Box 4, Bathurst Street, Greystanes. 2145.