PERSONAL INFORMATION

First Name:       Last Name:       Call Sign:

    Address:

          City:       State:       Zip:

  Home Phone:       Work Phone:

            Pager:          Cell Phone:

E-Mail Address:       Birth Date (mm-dd-yyyy): - -

RADIO COMMUNICATION INFORMATION

              License Class: SELECT LICENSE Novice Technician Technician-Plus General Advanced Extra

Primary Radio Interest:

Are you currently registered as a Disaster Service Worker (DSW)?     Yes     No
      If YES, enter Expiration Date (mm-dd-yyyy):

Check the boxes that correspond to the bands/modes you can operate.

 

	160m	80m	40m	20m	15m	10m	6m	144Mhz	222MHz	420Mhz	Other
CW
FM
RTTY
SSB
MOBILE
PACKET

If operating PACKET, the CALL SIGN of your PBBS is:

Can your Home Station Operate without commercial power?     Yes:     No:

If YES, indicate bands:

If you are interested in helping with the local weekly Net, Check here:
If you are interested in helping with the National Traffic System (NTS) Net, Check here:

...And FINALLY

Select the City/Emergency Coordinator (EC) to receive this registration.
When you select an EC and then click on SUBMIT, you will get a screen
that shows you what you have entered, and you will have the chance to
Submit that, or go BACK and correct it. If you have provided an E-Mail
address, you will be sent a copy of the information you provided.
This information will only be used for ARES/RACES activities and will
NOT be shared with outsiders without your permission.

SELECT CITY/EC Lowndes, Doug Scallions, KD5FUO Monroe, Doug Scallions, KD5FUO Oktibbeha, Doug Scallions, KD5FUO Clay, Doug Scallions, KD5FUO Noxubee, Doug Scallions, KD5FUO <