Eastern and Mountain District Radio Club (EMDRC)

Incorporated Association Number A0011163B

Signup / Renewal Form

* Membership Type

EMDRC Membership $35.00 for one year Membership fee for EMDRC members

Family Members

Enter additional family member names and/or callsigns for family memberships

* Payment System

PayPal secure credit card payment Offline Payment Direct deposit using the account details below

Offline payment

You may also pay by direct deposit using the following details:
Name: Eastern and Mountain District Radio Club Inc.
BSB: 033-058
Account: 144 876
Please put your name in the Description that appears in the receivers Statement.

User Information

* Preferred Name

this name will appear on your name badge

* Last Name

* Your E-Mail Address

a confirmation email will be sent to you at this address

* Choose a Password

must be 6 or more characters

* Confirm Your Password

Address Information

* Street

Street (Second Line)

* City

* State

Country

* Postcode

Member Details

Callsign

Members Callsign

Year of birth

Members year of birth

Occupation

Members occupation

Phone Number

WIA Member Number

Please enter your WIA Member Number (if applicable).

Agreement

By proceeding with the application for membership of the Eastern and Mountain District Radio Club Inc., you agree to comply with the rules and support the purposes of the association. The Rules of Association are available from the link in the footer of the web page.

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