OKDXA MEMBERSHIP APPLICATION

NAME:_______________________________________________ CALL:___________________

STREET ADDRESS:______________________________________________________________

CITY/STATE/ZIP:________________________________________________________________

PHONE NUMBER:_________________ E-MAIL:______________________________________

LICENSE CLASS:_____________________________ YEAR FIRST LICENSED:_____________

TOTAL CONFIRMED COUNTRIES:_______ ARRL MEMBER:_Y / N / Life (Circle one)_________

Dues enclosed:

$20.00 Regular Member ____

$10.00 Senior Member ____

$10.00 Handicapped Member ____

$ 5.00 Family Member ____

Mail Dues to: (payable to OKDXA)

BRUCE BURNETTE - K5PX
7 SPRING CREEK LANE
BROKEN ARROW, OK 74014

Other comments:___________________________________________________________________

THANKS FOR YOUR SUPPORT OF THE OKLAHOMA DX ASSOCIATION!