Chapter Application

Chapter Name:_________________________________________________________
Chapter Head: Call: ____________ 10-10# ____________ Phone (      )___________ Name:________________________________________________________________
Street or P O Box: ______________________________________________________
City, State, ZIP: ________________________________________________________
Proposed Net Operation: Start Date: __________________ Mode: _______________
Calendar Day: ________________ Time(local): ___________ Frequency: _________
UTC Day: __________________________ Time(Z): ___________________________
Nearest City to Chapter: _________________________________________________

List the Initial Group by Call, Name, 10-10 # and Expiration Date (enclose a copy of current dues cards)

     Call                  Name                                                   10-10#            Exp. Date
1. _________         ______________________________     _________     ________
2. _________         ______________________________     _________     ________
3. _________         ______________________________     _________     ________
4. _________         ______________________________     _________     ________
5. _________         ______________________________     _________     ________
6. _________         ______________________________     _________     ________
7. _________         ______________________________     _________     ________

Do you plan a certificate program? Yes / No

If yes, describe on a separate sheet and enclose a copy of the proposed certificate, list type of printing; quality of paper, etc or enclose a copy. What are the requirements for basic membership?


Do you plan any chapter activities such as newsletter, dinners, public service, etc.? Yes / No

If yes, please describe on a separate enclosed sheet. We will abide by the rules and By-laws of the 10-10 International Net, Inc. and will follow the directions of the Chapter Coordinator. We also agree to report on chapter activities quarterly as provided.

Signed___________________________________________Date_________________
                                                                                    Chapter Head
Rev 7-03

Submit application to:
Cliff Taylor - K5FBS - #48461
22707 Red Mountain Dr.
Elmendorf, TX 78112-6034
e-mail: CATK5FBS@aol.com