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)____________________________
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?______________________
Annual “VOICE” REPORT: ___Printed
____Emailed as PDF
Your Signature: __________________________ Date: ___/____/____ (mm/dd/yyyy)