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__________