Name: __________________________________________

Address: _________________________________________



Phone number: _________________________

Email address: ___________________________________

Initial each of the following:

______ I have read and agree to abide by the Dayton Diode Charter.

______ I have read and agree to abide by the Membership Agreement.

______ I have signed the Liability Waiver.

Applicant Signature: ___________________________________ Date: ____________

Officer Signature: _______________________________________ Date: ____________

Licensed under Attribution-Noncommercial-Share Alike 3.0 Unported based on the Hive 13 Membership Application

Consensed on by Dayton Diode membership on Nov 2, 2010.

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