KL7AA
Anchorage Amateur Radio Club, Inc.
PO Box 101987
Anchorage, Alaska, 99510-1987

VOLUNTEER EXAMINER APPLICATION FORM

PLEASE TYPE, OR PRINT CLEARLY IN INK:


NAME: ____________________________________________________ CALL: ______________________
                               First                                       Initial                                   Last

MAILING ADDRESS (line 1) _______________________________________________________________

MAILING ADDRESS (line 2) _______________________________________________________________

CITY: _______________________________________ STATE: _______ ZIP:____________ +4 _________

WORK PHONE:______________________Extn: _______     HOME PHONE:________________________

E-MAIL ADDRESS: ______________________________________________________________________

LICENSE CLASS:____________________________ EXPIRATION DATE:_________________________

HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? _____________

ARE YOU CERTIFIED BY ANY OTHER VEC? (Give name) ______________________________________

CERTIFICATION

1. I agree to comply with the FCC rules, and all terms and conditions set forth in the VEC manual
2. I agree to comply with the examination procedures set forth by the Anchorage ARC VEC Board
3. I understand this accreditation is only valid in the State of Alaska
4. I am at least 18 years of age
5. I agree to indemnify and hold harmless the Anchorage Amateur Radio Club, Inc., and it's agents for any action
    which it may take on my VE accreditation application, or in the event that my accreditation is withdrawn at a
    later date, regardless of cause, reasons, or circumstances.
6. I understand that violation of the FCC rules or willful non-compliance with the VEC will result in the loss of my VE 
    accreditation,  and could result in loss of my Amateur Radio operator and station licenses.

By my signature below, I certify that I have read and understand these requirements, and that 
all statements I have made herein are true.



____________________________________________                                         _______________________
Signature of applicant                                                                                                                                                          Date

Approvals: Signatures of 3 members of the Anchorage ARC VEC Board, with callsigns:


__________________________________________             _________________________________________


__________________________________________           _________________________________________
                                                                                                                      DATE APPROVED