Do not write in this space
OM# ________________
Date ________________

 
Formal Name _____________________________________
               (As it is to appear on the certificate)
First Name __________________     Your Call ____________
               (How you prefer to be addressed on the air)
Address _____________________________________
City _________________________       State __________________       Zip Code __________
County _________________________       Grid Square ____________
E-Mail Address: _______________________________     

Log Info of 2 OMISS Members Worked:

OM# _______    Call ________    Date _________    Freq _________    Time (GMT) _________
OM# _______    Call ________    Date _________    Freq _________    Time (GMT) _________

Roster Option:

____ I would like to pay $7.00 for lifetime membership and download my own roster.

____ I would prefer to pay $13.00 for lifetime membership, and receive a paper roster.

Print this form and send it with the lifetime membership fee you have selected to:

KA0AK
Dick Zenge
524 N. Russell
Snohomish, WA 98290

Make checks payable to OMISS.    DX Stations please use International Money Order or U.S. Currency.

I certify that the above information provided is correct.

 
Signed: _______________________________________