KD4RAA-K4JDR Repeater Group
Supporting Membership Form

Name	*
Call sign	*
Address	*
City	*
State	*	Zip *
Day Phone	*
Night Phone	*
Fax #
Cell Phone
Year of Birth	*	Today's Date *
Personal Email	*
Personal URL
Enter desired AutoDial Phone Patch Number
Vocation
Do you already know anyone in the KD4RAA Group?	*
Key Reason for Joining the KD4RAA Group	*
Area Clubs or Organizations	*
SERA member?	*	Yes             No
ARRL member?	*	Yes             No
Ham Interests
Technical Skills you can contribute to the group
How did you hear about us	*
Comments

Select one of the following options for suggested yearly donation:

       Associate Membership (repeater use, no user or IRLP codes) - $10

Autopatch and User Codes for UHF linking system - $15

IRLP and EchoLink full access codes - $15

Full Support Membership (all access codes) - $25

Repeater owners and trustees

(note: no funds will be collected at time of submission)