Date: Amateur Callsign:


E-Mail Address:

Address: City:State:

Zip: Phone: Business:

Fax: Hours Of Employment:

Can We Call You At Work: Will Your Employer Release You In Case Of Disaster:

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?Expiration Date:

Do you have HF Capabilities? Mobile HF? Portable HF?

Do you have VHF Capabilities? Mobile VHF? Portable VHF?

Do you have UHF Capabilities?   Mobile UHF? Portable UHF?

Do you have Packet Capabilities? HF? VHF?

Packet Home BBS (full path):


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