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Mail-in Membership Application
and Merchandise Form

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're creating an online form but that's still weeks away...)
(All membership numbers are listed at: http://www.coloradoqrpclub.org/cqcmems_master_list.htm)

State/Province:_____________________________  ZIP/Postal Code:_______________


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




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


Colorado QRP Club


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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