10 -10 Chapter Application Form

Chapter Name: 													
Chapter Head: Call: 		   10-10 #: 			    Phone: (       ) 		-		
Name: 														
Street or P O Box: 													
City, State, and ZIP: 												
Proposed Net Operation: Start Date: 					 Mode: 				
Calendar Day: 			  Time(local): 			  Frequency: 				
UTC Day: 							 Time(GMT): 						
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

Submit Application to:
James H Fox, KA0ZPP, #43428
PO Box 135
Mayhill, NM 88339-0135

© Copyright 2015 10-10 International.

Rev 15-05