Bullitt Amateur Radio Society P.O. Box 580 Shepherdsville, KY 40165-9998 Web Site: KY4KY.com

Call Sign: __________________ Class: __________________________ Expires: ___________________

Name    _________________________________________________ Date of Birth: ___________________

Address ____________________________________________________________________________________

City __________________________________ State __________  Zip Code+4 _______________________

Telephone Number (Include Area Code): __________________________________

Email Address: _____________________________________________________________________________

Web Site: __________________________________________________________________________________

I belong to the following radio clubs:

____________________________________________________________________________________________

I am an ARRL Member: (Circle One)   YES    NO    If yes, expires: __________________________ 

I am willing to work on a committee: (Circle One)   YES    NO    Undecided

My main interests in amateur radio are:

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Membership dues per year (Membership period is from January 1 through December 31.)

Full Members: Over 62 Years 0ld           $15 per year*
              Handicapped per FCC Rules   $15 per year*
              All Others                  $25 per year**
              Under Age 18 Years Old      No Cost***
              Additional Family Members   $5 per year (not pro-rated)

* Pro-rated May 1-Jul 15 $11; Jul 16-Oct 15 $7; Oct 16-Dec 31 $3.50
** Pro-rated May 1-Jul 15 $18; Jul 16-Oct 15 $12; Oct 16-Dec 31 $6
*** Must hold an amateur radio license for full membership.

An associate (non-voting) membership is available to unlicensed individuals for $5 per year,
not pro-rated.

Amount Paid ________________   Date __________________  Received By ________________________

Expires: _________________

THE BULLITT ARS IS AN
ARRL AFFILIATED
SERVICE CLUB