Yes, I would like to become a member of El Dorado County ARES
(Page Rev: 1/6/04)
(
*
Required Field)
Name First/Last:
*
Call Sign :
*
License Class
Extra
General
Advanced
Technician+
Technician
*
E-Mail:
P.O. Box:
Street Address:
*
City/St/Zip:
,
*
County:
*
Home Phone:
*
Business Phone:
PBBS Packet Call Sign:
SKYWARN #:
Completed Red Cross -
Intro Disaster Service Class:
Date
Have Portable
Emergency Generator :
Watts
Primary Radio Interest:
Participation Level:
ACTIVE STATUS
- I am committed to regular participation in meetings, training, drills, and other on-going activities and who constitute the core group of “prepared” ready-to-respond personnel.
RESERVE STATUS
- I am are willing to provide communications support in the event of a disaster or other emergency situation, but who prefer not to participate in meetings, training, drills and other activities on a regular basis.
HOME STATUS
- I would prefer working from home.
MODE
>
CW
FM
SSB
Mobile
Packet
Indicate the Bands/Modes
you can operate. Hold down
the "CTRL" key and click on
the Band/s
At least one selection MUST be made in each column for the form to process correctly
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I __________________________________________ affirm that I have never been convicted of a felony and that I have no outstanding warrants for my arrest and that I am not a fugitive from justice.
Signed ___________________________ date ___________ witness _______________ Identified by: CDL # (or other): ____________________ by __________________
(EC will provide copy to sign)
A confirmation E-Mail will be sent to the above E-Mail address.