ASHLAND, MA PEBMIT NO.7 - Quarter Century Wireless Association

QUARTER CENTURY WIRELESS ASSOCIATIOI{, II{C.
P.O. Box 3247, F ramingham, MA 017 05 -3247
508-40s-1930
Fax: 508-405- 1 965
or Official Use Only
This form for use by all U.S. Applicants
for membership in QCWA.
Fees Effective 41112047
NewApplication? Renewal? Original QC\IVA No.
t,
Membership No.
First Licensed Year
. Deposit Record
(Print Name Clearly) Present Call
having been licensed as an amateur far 25 years or more and presently holding the call listed above,
(it is not necessary to have been licensed the entire 25 years) hereby apply for membership in QCWA.
I understand that proof of the original date of licensing is required. My complete mailing address is :
Street Number and Name
E-MailAddress
City State Zip Code
Telephone Number
I will keep QCWA Headquarters advised of changes in my address and/or call sign. My firstAmateur
license was dated and the Callwas Other Calls held-
Date of Birth
I wish to become affiliated with QCWA Chapter
Select one of [he following plans:
QCWA Dues for a ONE-year period
QCWA Dues for a TWO-year period
QCWA Dues for a THREE-year period
QCWA LIFE Membership
When paid in 3 equal installments
within a one-year period
Your Signature
SCHEDULE OF MEMBERSHIP FEES
Member
$25.00
$40.00
$5s.00
$375.00
$3e0.00
(3 pay of $130"00)
Family Member
(ea. additional)
$12.00
$90.00
$10s.00
(3 pay of $35.00)
INITIAL REGISTRATION FEE, ALL NEW MEMBERS .,..$5.00
Gold membership pins available with your call engraved (no year tag) Check fastener:
Tie-tac Screw button Safety pin
$15.00 each
Year{ag pins (tie-tac only): 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 or 80 $20.00 each
Proposed by
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56 QCWAJournal . Summer 2OOO . ww\ /.qcwa.org
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No.
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