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 |
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Mobile |
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Portable |
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Emergency Power |
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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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