APPLICATION
W2LIS | www.w2lis.com | w2lis@aol.com

575 Long Island Amateur Radio Club
14 IVY Road,  Mastic Beach,  NY 11951

Membership Application

Please put your callsign on the check (made out to LIARS) and complete below:

Dues are $30 individual, $35 family



Name:__________________________________________Callsign:__________

Address:_________________________________________________________

City:____________________________________State:_______Zip:__________

Phone #:______________________________ Publish in Roster?  Yes[  ]    No[  ]

e-mail address:_________________________ Publish in Roster?  Yes[  ]    No[  ]

License:  [  ]Novice   [  ]Tech    [  ]Tech+   [  ]General   [  ]Advanced   [  ]Extra
ARRL Member:  Yes[  ]   No[  ]

[  ]Check to receive the Roster by e-mail-Valid e-mail address required

********************************************************************************************

Second member info (living in same household)

Name:__________________________________________Callsign:__________

Phone #:______________________________ Publish in Roster?  Yes[  ]   No[  ]

e-mail address:_________________________ Publish in Roster?  Yes[  ]   No[  ]

License:   [  ]Novice    [  ]Tech   [  ]Tech+    [  ]General    [  ]Advanced   [  ]Extra
ARRL Member:  Yes[  ]   No[  ]

[  ]Check to receive the Roster by e-mail-Valid e-mail address required



Amount Enclosed (there is room here to send in dues for two people)

Membership Dues expire December 31st of the current year

Total Enclosed: $_______________
If paying for more than 2 in your home, Please use an additional sheet.

I respectfully request that this application be considered by
the Officers and Directors of LIARS.



Date:___________ Signature:______________________________________________

[  ] Please check here if any info on this form has changed from last year

Dues expire December 31st of the current year


SEND APPLICATION via email to : w2lis@aol.com

or mail to :  
575 Long Island Amateur Radio Club
14 IVY Road,  Mastic Beach,  NY 11951


Or you can submit an online Application right here by using the form below and mailing in your check.

Application Form

Please use this form to submit an electronic application to join W2LIS
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