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Dues  $10.00 New member                                                                                                                                                       

                                                                                                                                    

     Mission Trail Net Membership Application

                                              Click here to Print an Application for mailing

 

Renewal______ New_______                                                                                             Date______________________________________

 

Call__________________ LicenseXClass_______________ ExpirationXDate__________ Handle____________________

 

Last Name_________________  First________________________  M.I_______ Date of Birth ___________(mo/day only)xxxxxxxxxx

 

MailXAddress__________________________________________City___________________________State_________

 

Zip_________________ County_______________________InternetXEmailXAddress_________________________

 

AreaXCode/HomeXPh.____________________AreaXCode/WorkXPh._____________________Extension____________

 

Occupation___________________________________________________________________________________________

 

PriorXCall(s)Xheld_____________________Hobbies/Interests_________________________________________

 

Spouse'sXName____________________Spouse'sXDOB_____________(mo/day only)XAnniversary Date_____________

 

Spouse'sXCall___________________SpouseXLic.XExpires__________________PriorXCall(s)Xheld_________________

 

Spouse'sXOccupation__________________________Hobbies/Interests____________________________________

 

Hobbies/Interests__________________________________________________________________________________

 

AreaXCoverage (forXtrafficXdelivery)__________________________________________________________________

 

Indicate if you wish to receive the Mission Trail Net newsletter (Blazer) every month  by email, or every other month by United States Postal Services mail   

Check one:       EMAIL______ (no fee)      USPS______ (additional $10.00/yr)

 

Mail dues and application to Dan Farrell, Treasurer, 534 No. Whittier Street, Anaheim, CA 92806-3055

 

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Last modified: 01/19/08