RADIO AMATEUR CIVIL EMERGENCY SERVICES

APPLICATION FOR MEMBERSHIP

LAST NAME:_________________ FIRST_____________ MIDDLE_______

CALLSIGN_____________ CLASS___________

HOME ADDRESS:______________________ CITY_________ ZIP ______

TELEPHONE (HOME) ____________

TELEPHONE (WORK) ____________

TELEPHONE (OTHER)____________

OCCUPATION__________________

EMPLOYER____________________

BANDS/MODES YOU CAN OPERATE: BASE_____________________________

MOBILE___________________________

PORTABLE_________________________

CAN YOU BE CONTACTED 24HRS/DAY IF NECESSARY?_______________(Y/N)

IF NO, WHAT HOURS CAN WE CONTACT YOU?___________________________

LIST ANY SPECIAL QUALIFICATIONS YOU HAVE THAT MAY BE OF ASSISTANCE DURING AN EMERGENCY:__________________________

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EMERGENCY CONTACT PERSON AND PHONE_______________________

DRIVERS LICENSE #________________________ (EXPIRATION DATE)__________

SOCIAL SECURITY #________________________

COMPLETION OF FEMA HS COURSE _________ (Y/N)

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