Membership Application/Renewal

Wheaton Community Radio Amateurs
P.O. Box QSL • Wheaton, IL 60187-1055 • (630) 923-5447
wcra@w9ccu.org • www.w9ccu.org
 Office Use Only
Cash $____
Chk# ____ $____
Dues Year: _______   Today: _______________
Full Membership $26 Student/Sr Citizen $13
Lifetime Member $0 Associate (no license) $13
Family/household $39
Family member of _____________________ $0

Club badge included
Year licensed: _________
Badge name:
________________________
ARRL logo   Pin
Notch  Magnet
Lanyard
Color:
white black
green brown
red blue
red, white & blue
Callsign: ________
Name: __________________________
Address: ________________________
City: ___________________________
State: ______ Zip: ____________
Home phone: ____________________
Work phone: _____________________
Cell phone: ______________________
Email: __________________________
Member Privacy Preferences

I grant to the Wheaton Community Radio Amateurs and its representatives and transferees the right to use specified references to myself as indicated on this form. Where indicated with a checkmark, I withold authorization from Wheaton Community Radio Amateurs, et al, to copyright, use and publish the same in print and/or electronically. Checked items withhold permission for the dues year shown above.

Request
Privacy
Photographs
Videos
Name

I agree that Wheaton Community Radio Amateurs may use such content of me with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising, and web content, published in the calendar "dues year" as shown above.

Signature ___________________________________________

Please indicate areas where you would like to assist or serve on a committee:
Repeater Advisory Board Meeting Programs Club Officer Membership
Public Service Events Field Day (June) Fundraising VE Testing
Training/Elmering On-Air Networks CSU Trailer Publicity
Hamfest (January) Youth Programs Newsletter Web site
Other: ____________________________