APPLICATION

TO JOIN THE

NUTMEG CHAPTER 149 OF THE

QUARTER CENTURY WIRELESS ASSOCIATION, INC

NAME________________________________CALL____________________________DATE_____________________________

ADDRESS_____________________________________________________________

                  ______________________________________________________________

                 _______________________________________________________________

DAY TIME TELEPHONE NUMBER____________________________EMAIL ADDRESS________________________________

Requirements:   You must have been licensed for  25 years  or more. You MUST BE A MEMBER in good standing of the

Quarter Century Wireless Association, Inc.      http://www.qcwa.org/membership-application-forms.htm

MEMBER OF QCWA, INC?____YES____NO         YOUR NATIONAL QCWA NO_____________

DATE FIRST LICENSED________________________________________

IS THIS APPLICATION ALSO FOR CLOSE RELATIVE OR SPOUSE LIVING WITH YOU?  IF SO:

NAME_____________________________CALL_______________________________FIRST LICENSED_________________

Mail  application to:  Anthony Perrone, Jr. W1CGI, 12 Oakwood Avenue, Pawcatuck, CT. 06379 with a check for $6.00 payable to " Nutmeg Chapter #149 QCWA"