NORTHEAST WISCONSIN DX ASSOCIATION
MEMBERSHIP APPLICATION
(Return to NEWDXA Membership Coordinator)

NAME:__________________________________________  CALL: ______________________________  

STREET: ________________________________________  PHONE: ____________________________

CITY: ____________________________________  STATE: ______________ ZIP: _________________

EMAIL:  _____________________________________________________________________________________

LICENSE CLASS: _____________________________  CURRENTLY AN ARRL MEMBER?         YES           NO

ARRL/DXCC certificate for basic 100 entities has been issued?:        YES      NO

Honor Roll member?           YES         NO

Latest TOTAL DXCC ENTITIES count per ARRL/DXCC desk: _______________________________

Latest TOTAL DXCC CURRENT ENTITIES count per ARRL/DXCC desk: _____________________

Are you currently a paid-up member of other DX associations, clubs, or foundations?  If so please list below: 

____________________________________________________________________________________________

____________________________________________________________________________________________

 Have you operated from a foreign country?  If so, please list country, call and date of operation.

_____________________________________________________________________________________

Are you a QSL manager for any DX station(s)?  If so, list below.

_____________________________________________________________________________________

Signature  _______________________________________________ Date __________________________

Reverse Side for Association Use Only
Please note: Prospective new members must be sponsored by a current NEWDXA member.

Association Use Only

Application received (date): ____________________________ 

Sponsor (call):    ______________________________________      

Membership approved (meeting date): _____________________

Membership number (#): ________________________________  

Certificate issued (date) : ________________________________

The NEWDXA Membership Coordinator will hold and file all applications.