Membership Application

BICYCLE MOBILE HAMS OF AMERICA
C/O Mike Nickolaus, NF0N
316 E. 32nd St. - I
South Sioux City, NE 68776-3512

date _________  Individual (US or Canada) $10_______ Foreign $15 __________
Family (limit: two persons) $15 ________  Donation $__________
New member? __________  Renewal? __________

Make check payable to BMHA, in US dollars or international money order.

Name _________________________________  Call __________

Address ________________________________ License Class ___________

City ___________________________  State _____________  Zip ____________

E-mail address __________________ @ _____________________

Year of birth ___________  Most miles bicycled in one day ___________________

I will receive the BMHA Newsletter via eMail at the address above.

rev. 2004-04-04