Name: _______________________________________________

Address: _____________________________________________

City: _________________________________ State: __________

Call Sign: ______________________ Class: _________________

Telephone; ________________________________    with area code

E-mail: ______________________________

Permanent Resident                        yes                No                Please circle one

If family membership please list all members in same house hold

_______________________ Relation__________     _______________________ Relation__________

_______________________ Relation__________     _______________________ Relation__________

Mail to :

P.R.R.A.

PO Box 510943

Punta Gorda, FL

33951-0943