Short Mountain Repeater Club, Inc.

       W4YXA/R  146.910-310

              Membership Information Form

Date: _____________________

Name: _____________________________ Call: ______________

Address: ______________________________________________

City: _____________________  State: _____   Zip: ____________

Phone: (Home) __________________  (Work) ___________________

E-Mail: _______________________________________________

ARRL Member: Yes _____  No _____  Exp. Date _____________

Dues are prorated for joining during the months of:
 

                                                                              Single                   Family

January – February – March                             $25.00                   $35.00

April – May – June                                             $22.50                   $32.50

July – August – September                                 $20.00                   $30.00

October – November – December                      $17.50                   $27.50

Please Make Checks Payable to:  Short Mountain Repeater Club

If sending your membership dues please mail to: 
5701 Briarwick Court; Hermitage, TN 37076

You may make application for ARRL membership through the club.  Send your form
with a check payable to Short Mountain Repeater Club to the address above.  (The club
receives a rebate for applications submitted by the club).