MIT UHF REPEATER ASSOCIATION

	MEMBERSHIP APPLICATION FORM FOR ACADEMIC YEAR 1999-2000

	This form should be filled out by people wishing to join the
	club who are not currently MIT students, faculty, or staff
	(Lincoln Lab and CSDL employees are considered MIT staff).

	Please enclose no money or checks now.  The student officers
	will review your application before the next meeting and
	notify you whether or not it has been accepted.  If it is
	accepted, you will be asked to remit dues and the patch fee if
	you stated you wish to join the patch.  Dues are $2/year and
	the patch fee is $10/year for nonstudents.



	DATE: ______________


	NAME: ________________________________________________________________


	ADDRESS: _____________________________________________________________


	PHONE:  __________   OTHER PHONE: __________________


	EMAIL:  ____________________________________________


	STATUS:
	 Non-affiliate ________

	 Alumni class of _______  active as student  ______ to ______

	CALL: ______    LICENSE CLASS: __________


	Do you wish to join the autopatch?  ______



	SIGNATURE: ___________________________________________________________