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 

Updated 07-15-2003

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