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 (65 or more) ____

$10.00 Handicapped Member ____

$ 5.00 Family Member ____

Mail Dues to: (payable to OKDXA)

Oklahoma DX Association
P.O. Box 1258
Broken Arrow, OK 74013

Other comments:___________________________________________________________________

THANKS FOR YOUR SUPPORT OF THE OKLAHOMA DX ASSOCIATION!

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