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CQC

Mail-in Membership Application
and Merchandise Form
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This is our mebership and merchandise order form - please print and mail it to us using the address further below

If this is a Brand New Membership Please Check Here:_________
(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 your your contact info is always current with us.
- We do not give out your personal info!)

 

 

Additional family members are $2.00 USD each.
Please list each of their names and callsigns here:
 
Name:_______________________________ Callsign:___________ 
 
Name:_______________________________ Callsign:___________ 
 
Name:_______________________________ Callsign:___________ 
 

 

I am enclosing payment for:

Membership: __________________

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

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

 

Please Mail your Payment and this Completed Application to:
Colorado QRP Club
P.O. Box 17174
Golden, CO 80402-6019

 

Questions?

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: _________________     Business Phone:___________________  FAX: _________________

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

 

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