Colorado QRP Club Membership Application

CQC

Mail-in Membership Application
and Merchandise Form Line

This page is for those who are not PayPal. Note: Due to PayPal's high costs we ask that you only use PayPal for oders of more than $18 USD Please print this page, fill it out, and mail it with your payment to: Colorado QRP Club P.O. Box 17174, Golden, CO 80402-6019 USA

If this is a New Membership Please Check Here:_________
If this is a renewal, please place your membership number here:__________
(All membership numbers are listed at: http://www.cqc.org/cqcmems.htm)

Callsign:___________________________
Name:_____________________________
Address:___________________________
City:_______________________________
State/Province:_____________________________ ZIP/Postal Code:_______________
Country:____________________________
email:_____________________________________________________________ (we do not give out your email address!)

Additional family members are $2.00 USD each.
Please list each of their names and callsigns here:
(Each will receive their own membership number but
only one Low Down will be mailed to the above address)

Name:_______________________________ Callsign:___________
Name:_______________________________ Callsign:___________
Name:_______________________________ Callsign:___________

$6.00 USD U.S. membership for one year
$8.00 USD DX (Foreign) membership for one year
$2.00 USD for each additional family member at the same address
Please indicate how many years you are applying for

I am enclosing payment for:

Membership/Subscription: __________________ year(s).

Merchandise (list items): _______________________________________

Total USD Enclosed (includes shipping): $____________

Please Mail your Payment and this Completed Application to:

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: _________________ 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: ______________________________________________

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CQC Webmaster
Roger J. Wendell, WBØJNR