Full Name :   CallSign: License Class:

Address :   City:   State: Zip Code : 

Phone : Home   Work Fax   Beeper

Employer:

Hours of Employment:     May we call you at work: Yes  No

General Information

Date of Birth:   Blood Type:   Allergies:

Hair Color:   Eye Color:   Complexion:

Are you a member of any other Emergency or Disaster Group?  Yes  No

If yes Explain:

Do have HF capabilities ? Yes  No              Mobile  Portable  RTTY

Do you have VHF capabilities ?  Yes  No             Mobile  Portable

Do you have UHF capabilities ?  Yes  No             Mobile  Portable

Do you have Packet capabilities ? Yes  No           HF  VHF  UHF    Portable

Packet Home BBS (Full path - ie: kb1ckf@ka1tuz.fn42jh.ema.ma.usa.na)

List any skills you have that may be useful in an emergency:

:

Date Submitted: