S.C.A.R.A. Amateur Radio Club

Optional Autopatch Slot Request

Today's Date: (MM/DD/YY)

   Call Sign: 

  First Name:   Middle Initial: 

   Last Name: 

  Home Phone: 

Email Address:

Your Member Number: 

Requested New Auto Dial Phone Number:

Name For Autopatch Slot: 

Who's Phone is this, Home,Work, ect :

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