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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