QUARTER CENTURY WIRELESS WOMEN - CHAPTER #120 QCWA
                    Membership Application and Info Sheet


     I hereby apply for Membership in the Quarter Century Wireless Women
     Chapter of the Quarter Century Wireless Association - a chapter
     dedicated to encouraging qualified women amateurs to actively
     participate in QCWA activities.

     I agree to support the purposes of the Chapter and abide by its By-laws.

                                      Signed ________________________________

                                                    QCWA # __________________

   Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Call_ _ _ _ _ _ _ _ _ _ _ _ _ _

   Address _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

   Telephone Number ( ___ ) ____ - _____

   QCWA Membership Expiration Date _ _ _ _ _ License Expiration Date_ _ _ _ _

   **************************************************************************
   *                                                                        *
   * We would like the following information for our files.                 *
   *                                                                        *
   * Birthday - Month ___ Day ___   Wedding Anniversary - Month ___ Day ___ *
   *                                                                        *
   * OM (XYL) - Name _ _ _ _ _ _ _ If Licenses - Call _ _ _ _ _ _ _ _ _ _ _ *
   *                                                                        *
   *                  Birthday - Month ___ Day ___                          *
   *                                                                        *
   * Other Clubs __________________________________________________________ *
   *                                                                        *
   * ______________________________________________________________________ *
   *                                                                        *
   * Hobbies ______________________________________________________________ *
   *                                                                        *
   * ______________________________________________________________________ *
   *                                                                        *
   **************************************************************************

        ANNUAL DUES $5.00  Per Year.      Send to the Secretary:
                                              Lorraine Witkowski, WA1EDR
                                              812 NcCallister Ave.
                                              Sun City Center, FL 33573



     Use the print function on your browser to create a copy of this form.