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* Name Badge Name (Must be filled in)
Callsign License Class Tech Tech+ General Advanced Extra
ARRL Member
Street Address
City
State Zip Code
1st Phone Type Home Cell Work Other
2nd Phone Type Home Cell Work Other
Email
Additional Name #1
Additional Callsign #1
Additional Name #2
Additional Callsign #2
Additional Name #3
Additional Callsign #3
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