November 2017 Technician Class Licensing Course
Welcome to the Bear Bait Radio Club.

Please use this form to register for our next class to be held in the Town of Clay, November 18th and 19th, 2017.

Also PLEASE, register only one person per form. If you experience difficulty completing the form, you may register directly with the instructor, Scott Marriam, via email at kb2bdb@twcny.rr.com.

Deadline for registration is Saturday November 11, 6 PM.

Thank you.

Email address *
Last Name *
Your answer
First Name *
Your answer
Phone number *
Please provide a contact number in case of course cancellation or schedule change. Please include the area code and use the following format: (XXX) XXX-XXXX
Your answer
Mailing address *
House Number, Apt Number (if applicable) and Street
Your answer
City *
Your answer
State *
If your state isn't listed, please provide the 2 letter abbreviation for your state of residence.
Zip Code *
Your answer
Optional: Due to the lack of places to buy food nearby, lunch will be available for a small fee on both days. Please check below as appropriate:
How did you hear about our course? *
So we can analyze the effectiveness of our advertising, please let us know how you found out about this course.
A copy of your responses will be emailed to the address you provided.
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