Online Membership Application

Applicant Information

First Name *Middle InitialLast Name *Suffix Email Address *Primary Phone *Secondary PhoneMay we send text messages?

Emergency Contact Information

Emergency Contact NameEmergency Contact PhoneAvailable for Emergency Communications?

Membership & Payment

Request *Requested Effective / Join DateMembership TypeDues Payment StatusAmount PaidDues Expiration Date

Address

Street Address *Apartment / SuiteCity *State / Province *ZIP / Postal Code *Country

Radio and Club Information

Amateur Callsign *GMRS CallsignCurrent License Class *New Licensee? Current ARRL Member? *Previous LARC Member? Are you interested in an upgrade class?How did you hear about the club?

Other hobbies or interests

Favorite bands and modes

Volunteer Interests

Help on committees, as an officer, or on the board?Willing to serve on committees?Willing to serve as an officer or director?Help with club events?Help with hamfests?

Do you belong to any other radio clubs?If yes, list the clubsPositions held or currently held with other clubsIf yes, list the positionsFamily members applying with youIf yes, list names and call signs

Activities and/or Committees Which Interest You

Certification

Full Legal Name / Electronic Signature *Bylaws Agreement *Dues Acknowledgement *Additional Notes or Comments