Emergency Response Team Application

Please Print and Return to: Boston Amateur Radio Club ERT  P.O. Box 15585  Boston, MA 02215-0011

Full Name:  Call Sign: 
Name Used on the Air: License Class:
Address: Apartment Number:
City: Zip Code: Fax:
Evening Phone: Other Phone:
Day Phone: Pager:
E-Mail: Web Page:

Please indicate your Amateur Radio equipment and capabilities:

TYPE

80m - 40m

24m - 15m

10m - 6m

2m

1.2m

70cm

other

Fixed

              

Mobile

              

Portable

              

Emergency Power

              

APRS/Packet

              

Packet Address if applicable.

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Other Capabilities:

 
 

Signature: _____________________________________        Date: ________________

Reviewers Comments (BARC ERT USE ONLY)       Do not write in this space

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