Polk County Amateur Radio Emergency Service Application

Thank you for your interest in joining Polk County Amateur Radio Emergency Service.
Please take a few minutes to complete this Application.

Should you have any question, please contact the ARES EC Robin Retzloff, AF1RE,
for more information email:

Name:

Callsign:

Over 18?

County of Residence:

Address:

City:

State:

Zip

Home Phone Number:

Work Phone number

Cell Phone

Email Address:

Class of License:

Are you a ARES member:

IF NO, CHECK HERE IF YOU WANT TO JOIN

Requested Membership Status

Please Read This

Do you own a HT:

For Which Bands?:

 2 METERS  220:  440:  1.2 GHz:  DUAL BAND:  TRI BAND: DIGITAL VOICE:

Do you own a Mobile Rig?:

For Which Bands?:

 2 METERS:  220: 440: 1.2 GHz:  DUAL BAND:  TRI BAND:  MOBILE HF:

Can You Operate HF::

 

For Which Bands?:

160 Meters: 80 Meters: 75 Meters: 60 Meters: 40 Meters: 20 Meters: 17 Meters:

10 Meters:  6 Meters:

What are your Ham Interests:

Do you own a 4 Wheel Drive:

 

  Do you have any health problems or disabilities which might restrict your activity?

 

 Are you available to assist on a Communications Assistance Team (CAT) in disaster areas elsewhere for periods of up to one week at a time?

 

Have you submitted a Polk County Volunteer Application within the last year?

 

 Please enter any special comments related to "CAT" activities here