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Word Format CLICK HERE Membership Form This membership form will be used to update the SRCHA Membership Database. We then use this information for tracking membership dues and newsletter/event mailings. AMA Number: [Required] ________________________________ Date: ____________________________________ Name: [Required] _______________________________________________________________________________ Address: [Required] ______________________________________________________________________________
City/State/Zip: [Required] _________________________________________________________________________
Mailing Address: ___ Same as Above ___ Other _____________________________________________________
Phone: Home: [Required]___________________________ Work: [Optional] _________________________________
Internet Mail Address: ____________________________________________________________________________
Radio Frequencies Used: [Required]_________________________________________________________________
Types of Membership: _____ Single Membership ______ Family Membership
Note: There is a $25.00 one-time initiation fee for new members
For a Family Membership please include the name of the other family members and their AMA membership numbers below:
Name: _______________________________________________________AMA #: ___________________________ Name: _______________________________________________________AMA #: ___________________________ Please send check or money order to: SRCHA Membership Phil Baird 1505 Single Membership Amount: ($25.00)***********************************************************************= $_____________________ Family Membership Amount: ($50.00)***********************************************************************= $_____________________ Initiation Fee Amount: (One Time Only $25.00 Fee Per Member)********************************= $25.00 (X)______Total $________
Total Amount Due =$______________________ In Case of Emergency Please Notify:
Name: ________________________________________________________Relationship______________________
Address:_______________________________________________________________________________________
City/State/Zip: __________________________________________________________________________________
Phone: Home: _____________________________________ Work: _______________________________________
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