Untitled - Quarter Century Wireless Association

I,
QUARTER CENTURY WIRELESS ASSOCIATION, INC.
159 East 16th Ave, Eugene, OR 97401-4017
(503) 683-0987
FAX (503) 683-4181
This form for use by all U.SApplicans
for membership in QCtf(rA
Effective 1O/lD3
Have you beer previously effolled in QCVA ?
For Office Use Only
Membership No
Fist Licemed. Year
Deposit Record
( Print Name Clearly) Present Call
having been licensed as an amateur 25 or more years ago and presently holding the call listed above
(it is not necessary to harre been licensed the entire 25 yens) hereby apply for membership in QCVA..
I understand that proof of the original date of licensing is reqtrired. My complete mailing address is :
Street Number and Name City State
I will keep QCNflA Headquarters adyised of changes in my address and/or call sign.
license was issued . Other calls held
I wish to become alfiliated with QC!(rA Chapter
Date of Birth Birthplace
Present occupation / business
If retired, what was major life work ?
Other organizations you belong to
Your Signature
SCHEDULE OF MEMBERSHIP FEES
Select one of the following plans Members
Proposed by
QCWA Dues for a one-year period
QCWA Dues for a two-year period
QCWA Dues for a three-year period
QCWA Life Membership
Payable in 3 equal installments
of$80.00 each, in a one-year period
Initial registration fee, all new members $3.00
$15.00
$2s.00
$35.00
$225.00
s240.00
Family
12.00
90.00
105.00
(3 pay of $35.00 )
Gold membership pins are available, your call engraved, no year tags Check fastener.
Tie-tac_, Screw button
-,
Safety Pin
$10.00 each
Year tag pins, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70 or 75 tie-tac only $15.00 each
Call_, No.
Total
Zip Code
My lirst Amateur
31 Spring 1994