Complete this form and mail *(or email) to:

Bill Phillips-W7AJP, 87298 Chinquapin Loop, Veneta, OR 97487

NOTICE: Renewals by US members may submit a check from a U.S. Bank for $20 or Pay via PayPal the sum of $21.  All DX must use PayPal as we cannot accept non-U.S. bank checks or money orders.

Make $20 personal US check or U. S. Money Order payable to “YLISSB.” ALL DX stations must use PayPal.

CALLSIGN: ____________ NAME: (ON LICENSE)____________________________

MAILING ADDRESS:____________________________________________________________

CITY:___________________ STATE:_______ ZIP:________COUNTRY:__________

CLASS OF LICENSE:_____________ YOUR NICKNAME:_____________________

PHONE NUMBER________________ (Non-published) EMAIL:__________________

Birthdate: MONTH:________ DAY_____ YEAR  ______ (Yr. Optional)

Anniversary:  Mo:___ Day ___ Yr ____  OM's/XYL's first name: ________________

ARE YOU A VETERAN? __________  Branch of Service: _____________________

Have you ever been issued an SSB’er number before: YES: ____ NO: ____

If Yes: under what call sign?______________________

ARRL Member?____________

Annual “VOICE” REPORT:  ___Printed   

                                                ___CD mailed   

                                                ____Emailed as PDF

Your Signature: __________________________  Date: ___/____/____ (mm/dd/yyyy)