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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 Evans Mitchell, KD4EFM,
for more information email:

Name:
Callsign:
County of Residence:
Address:
Phone Number:
Email Address:
Class of License: NOVICE TECH GENERAL  EXTRA
Are you a ARES member: YES NO IF NO, CHECK HERE IF YOU WANT TO JOIN CHECK HERE IF YOU WANT MORE INFO
Do you own a HT: YES NO 
For Which Bands?:  2 METERS  220:  440:  1.2 GHz:  DUAL BAND:  TRI BAND: DIGITAL VOICE:
   
Do you own a Mobile Rig?:  YES NO
For Which Bands?:  2 METERS:  220: 440: 1.2 GHz:  DUAL BAND:  TRI BAND:  MOBILE HF:
   
Can You Operate HF::  YES NO
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:  YES NO
   
  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?  YES NO
   
   
   
   
Have you submitted a Polk County Volunteer Application within the last year?  YES NO
 Please enter any special comments related to "CAT" activities here
   
 

 
 


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Last modified: October 25, 2008