UARC – Utah Amateur Radio Club
Membership Application
Membership Application
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Application Type
*
New Application
Renewal
Primary Applicant Name
*
Primary Member Call Sign
Primary Applicant Phone 1
*
Primary Applicant Phone 2
Primary Applicant Email
*
Primary Applicant Publish Data
*
Can we publish information in membership directory?
Yes, I authorize my name, address, and number be published
Yes, I authorize only my name and number be published
No, do not publish any information
Maybe, please contact me for more information
Membership Type
*
Individual Membership
Dual Membership (Additional Family Member)
Primary Applicant Nickname
Primary Member License Class
*
Please select your License Class (Required)
Unlicensed
Novice
Technician
Technician Plus
General
Advanced
Extra
Primary Applicant Phone 1 Type
*
Primary Phone Type (Required)
Cell Phone
Home Phone
Work Phone
Other
Primary Applicant Phone 2 Type
Alternate Phone Type
Cell Phone
Home Phone
Work Phone
Other
Primary Applicant ARRL Membership Status
Are you an ARRL Member?
Yes, current active member
No, not interested
No, but please contact me in regard to membership
Dual Membership Information
Below, please enter the information for the additional family member you wish to include on this application. The family member must reside at the same address as yourself. If you do not have an additional family member you wish to include, please scroll back to the top of this form and select Individual Membership under Membership Type.
Secondary Applicant Name
*
Secondary Member Call Sign
Secondary Applicant Phone 1
Secondary Applicant Phone 2
Secondary Applicant Email
Secondary Applicant Publish Data
*
Can we publish information in membership directory?
Yes, I authorize my name, address, and number be published
Yes, I authorize only my name and number be published
No, do not publish any information
Maybe, please contact me for more information
Secondary Applicant Nickname
Secondary Member License Class
*
Please select License Class (Required)
Unlicensed
Novice
Technician
Technician Plus
General
Advanced
Extra
Secondary Applicant Phone 1 Type
Primary Phone Type (Required)
Cell Phone
Home Phone
Work Phone
Other
Secondary Applicant Phone 2 Type
Alternate Phone Type
Cell Phone
Home Phone
Work Phone
Other
Secondary Applicant ARRL Membership
Is the additional applicant an ARRL Member?
Yes, current active member
No, not interested
No, but please contact me in regard to membership
Physical Address
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address, if different from above
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Authorizations
Liability Waiver
*
I release the Utah Amateur Radio Club Inc, (UARC) its officers, contractors, event organizers, and/or person(s) within this organization from all liability and responsibility when participating or attending club meetings or events.
Acknowledgement
*
I understand and agree that this membership to the Utah Amateur Radio Club Inc, (UARC) is valid for only the membership term selected and is non-transferable and non-refundable.
The below membership fees are for individual membership only. If you have an additional family member, living at the same address as yourself, that you would like to include on this application, please scroll back to the top of this form and select Dual Membership under Membership Type. The membership fees will update for different membership type.
Individual Membership Types
*
($ 20.00) Stnd12 – 1 Year (Individual membership for 12 months from application date)
($ 40.00) Stnd24 – 2 Year (Individual membership for 24 months from application date)
($ 60.00) Stnd36 – 3 Year (Individual membership for 36 months from application date)
($500.00) Life99 – Lifetime Membership
The below membership fees are for dual or family memberships only. They are intended to add (1) additional family member that resides at the same address as yourself. These are offered at a discount from multiple individual memberships. If you do not have an additional family member you wish to include, please scroll back to the top of this form and select Individual Membership under Membership Type.
Dual Membership Types
*
($ 32.00) Duo12 – 1 Year (Individual membership plus (1) Family Member residing at the same address for 12 months from application date)
($ 64.00) Duo24 – 2 Year (Individual membership plus (1) Family Member residing at the same address for 24 months from application date)
($ 96.00) Duo36 – 3 Year (Individual membership plus (1) Family Member residing at the same address for 36 months from application date)
Membership Physical Member
Total
$0.00
PayPal Commerce
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Credit Card
Card Number
Expiration Date
Security Code
Card Holder Name
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