Please print

Name: __________________________________________ Date: ______________

Address: _________________________________________________________________

City/Town _________________________ State _______ Zip Code: ___________

Tel. ___________________ Cell Phone: ___________________ E-mail: ______________________

A.M.A. Number ______________ Date of Birth: ______________

( ___ ) Regular Membership Annual Dues $75.00

( ___ ) Junior Membership (under 18 years old) Annual Dues $25.00

Areas of Radio Controlled Model Interest

( ) Airplanes ( ) Helicopters ( ) Boats ( ) Cars Others: ___________________

Do you need instruction? Yes ______ No ______

How did you hear about the club: ____________________________________________________

Newsletter Preference: _____ electronically (e-mail) ______ paper copy via US mail

Signature: ___________________________________________

Amount enclosed: _______________ (make checks payable to Northeast Radio Control Model Club)

For Club use only

Date received: __________________

Card mailed: ___________________

Please return to:

George Denault, Clerk

P.O. Box 12

Merrimac, MA 01860