Colorado QRP Club Membership Application

CQC

Mail-in Membership Application
and Merchandise Form Line

This is our mebership and merchandise order form - please print and mail it to us using the address further below

If You're Only Using This Form For Membership Please Check Here:_________

(Membership is FREE but we'd appreciate you submitting this application form even if you're not purchasing anything. We do accept donations through Zelle using coloradoqrpclub@gmail.com - we are not tax deductible)

(All membership numbers are listed at: http://www.coloradoqrpclub.org/cqcmems_master_list.htm)

Callsign:___________________________

Name:_____________________________

Address:___________________________

City:_______________________________

State/Province:_____________________________ ZIP/Postal Code:_______________

Country:____________________________

email:_____________________________________________________________

Please ensure that your contact info is always current with us.
- We do not give out your personal inforomation without your permission!)

Please send your completed membership application to our club address (below)

Additional family members:
Please list each of their names and callsigns here:

Name:_______________________________ Callsign:___________

Name:_______________________________ Callsign:___________

Name:_______________________________ Callsign:___________

I am also enclosing a payment for:

Merchandise, other items, or a donation (Note: Donations are not tax deductable):

(list items): _______________________________________

(list items): _______________________________________

(list items): _______________________________________

Total USD Enclosed (include any shipping for merchandise): $____________

Please mail your completed application (and any payments):
(Note: we're working to replace this form with an online version but that's still weeks away!)

Colorado QRP Club
P.O. Box 17174
Golden, CO 80402-6019

The following information is optional, but would be of interest if you provided it:

ARRL Member? [ ]YES [ ]NO

Your Web Page URL:_______________________________________________________

Home Phone: _________________ Mobile Phone:___________________ Business: _________________

License Class: [ ]EXTRA [ ]ADVANCED [ ]GENERAL [ ]TECHNICIAN
[ ]TECHNICIAN PLUS [ ]NOVICE [ ]FOREIGN [ ]NONE

Other QRP Club Memberships: _____________________________________________________

Occupation: ________________________________________________________

Are you... [ ]Active in QRP? [ ]Inactive? [ ]New to QRP? [ ]Interested in QRP?
If Active, on what bands? _____________________________________________

QRP Interests: [ ]Operating [ ]Technical [ ]DX [ ]Contests [ ]Construction [ ]Portable
[ ]Mobile [ ]VHF/UHF [ ]QRPp [ ]Digital [ ]Antennas

Other QRP Interests: ________________________________________________________
QRP Equipment you own/use: ______________________________________________

Privacy Notice: The Colorado QRP Club recognizes that privacy is very important to our members, and we pledge to protect the security and privacy of any personal information members provide to us.

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CQC Webmaster
Roger J. Wendell, WBØJNR