Name: Call:

AMATEUR RADIO EMERGENCY SERVICE

REGISTRATION FORM

Address:
City: State/Prov: Zip/PC:
Bus Phone: Home Phone: County:
License Class: Primary radio interest:

Check (√) bands/modes you can operate:

 
 

160 

80 

40 

20 

15 

10 

220 

440 

Other 

CW 

                     

FM 

                     

RTTY 

                     

SSB 

                     

Mobile 

                     

Port/HT 

                     

Packet 

                     

If operating packet, the callsign of your PBBS is: 

Can your home station operate without commercial power? Yes No
If yes, what bands?  
Signed: Date: