Fill out this form and the form on the previous page
to print for mail in orders.

NAME:__________________________  CALLSIGN________________

STREET:____________________________________________________

CITY:_______________________________________________________

STATE:_________ POSTAL CODE _________ Country____________

PHONE:_______________________________

VISA/MC/AMEX #  __________________________________________

EXPIRES:_________ SIGNATURE_____________________________

E-MAIL ADDRESS ___________________________________________

ARE YOU CURRENTLY ON ATV ?  _____ YES _____ NO

ARE YOU CURRENTLY ON SSTV ?  _____YES _____ NO

DO YOU USE AN ATV REPEATER ? _____ YES _____ NO

CALL OF THE REPEATER _________ LOCATION ______________

REPEATER HAVE A WEB PAGE ? http:// ______________________

ATVQ, 135 Wilson Ave.,  Machesney Park, IL 61115 - PHONE: 815-543-0894

ORDERS TO ATVQ 1-815-543-0894

>>FAX 815-398-2688<< >>>> E-MAIL ATVQ@hampubs.com