Date: Amateur Callsign:

Name:

E-Mail Address:

Address: City:State: AL AS AZ CA CO CN DL FL GE HA ID IL IN IO KA KN LO MA MY MS MI MN MS MT MO NE NV NH NJ NM NY NC ND OH OK OR PN RI SC SD TN TX UT VR VI WA WV WI WY

Zip: Phone: Business:

Fax: Hours Of Employment:

Can We Call You At Work: Yes No Will Your Employer Release You In Case Of Disaster: Yes No

Date Of Birth: Height: Weight:

Blood Type: Hair Color: Complexion:

Are you a member of any other emergency or disaster group?

What Class Of Amateur License Do You Hold? Novice No-Code Technician Tech-Plus General Advanced Extra Expiration Date:

Do you have HF Capabilities? Yes No Mobile HF? Yes No Portable HF? Yes No

Do you have VHF Capabilities? Yes No Mobile VHF? Yes No Portable VHF? Yes No

Do you have UHF Capabilities? Yes No   Mobile UHF? Yes No Portable UHF? Yes No

Do you have Packet Capabilities? Yes No HF? Yes No VHF? Yes No

Packet Home BBS (full path):

List Any Special Skills You Have That Would Be Useful In An Emergency: