Name: 
    Call sign: 
     Address1: 
     Address2: 
         City:   State: 
  Postal code: 

       E-mail: 
  Phone (Day): 
  Phone (Eve): 

  I hereby apply for the following appointment(s):
                Official Relay Station
                Official Observer
                Technical Specialist
                Local Government Liaison
                Official Emergency Station **
                Public Information Officer

  My qualifications are:
      

  ** (For OES only) Recommending EC/DEC (Name/Call sign):
      


   I agree to maintain current League membership, and report my
      station activity on a regular basis.