VICTORIA NEW HORIZONS AMATEUR RADIO CLUB
PO BOX 5295 STN B
VICTORIA BC V8R
6N4 CANADA
Your
name:__________________________________________Phone:(
)_______________
Address:__________________________________________________Apt#:________________
City:_____________________________Prov/State:_______________Post
or Zip Code_______
Date of Birth:
______/______________/___________
Day
Month
Year
E-Mail:_________________________________________Fax:(
)____________________
Do you have a certificate of
proficiency in Amateur Radio?
Yes ( ) No
(
)
Your present call
sign:__________________Previous call signs
held:______________________
Are you out of the regular
work force? Yes ( ) No (
)
Name of Spouse
:_______________________________Date of birth:
____/__________/______
Day
Month
Year
Wedding anniversary date:
_______/_____________________/___________
Day
Month
Year
Membership fees are
$6:00
per year
(January 1st to December 31st)
Enclosed is: ( ) Cheque ( ) Money order ( )
Cash
Your
signature:______________________________Date :
______/________________/_______
Day
Month Year