LANCASTER COUNTY ARES/RACES
MEMBERSHIP APPLICATION
NEW MEMBERSHIP [ ]      RENEWAL [ ]
(please print)




     CALL SIGN___________________ LICENSE CLASS___________________
     NAME_________________________________________________________
     ADDRESS______________________________________________________
     CITY_____________________________ COUNTY_____________________
     STATE____________________________ ZIP________________________
     HOME PHONE_______________ WORK______________ PAGER___________
     EMPLOYMENT___________________________________________________
     INTERNET EMAIL ADDRESS_______________________________________
     BACKUP EMAIL ADDRESS(S)______________________________________
     DRIVERS LICENSE NUMBER__________________________ STATE_______
     BIRTH PLACE & DATE (optional)________________________________
     ARE YOU A MEMBER OF A LOCAL AMATEUR RADIO CLUB? YES[ ]  NO[ ]
     IF YES, NAME(S) OF CLUB(S):__________________________________
     _____________________________________________________________
     _____________________________________________________________

     DO YOU HAVE SKYWARN TRAINING? YES[ ]  NO[ ]  WANT TRAINING[ ]
     DO YOU HAVE RADIOLOGICAL MONITORING TRAINING?  YES[ ] WANT[ ]
     DO YOU HAVE HAZARDOUS MATERIALS TRAINING?      YES[ ] WANT[ ]
     DO YOU HAVE ANTI-TERRORIST/SABOTAGE TRAINING?  YES[ ] WANT[ ]
     WANT TRAINING IN ANY/ALL OF ABOVE?             YES[ ]  NO [ ]

     IF YES, WHICH CLASSES?:______________________________________

     _____________________________________________________________

     ARE YOU A MEMBER OF A.R.E.S. YES[ ]   -OR-  M.A.R.S.?  YES[ ]
     ARE YOU AN EMERGENCY COORDINATOR FOR ARRL'S A.R.E.S.?  YES[ ]
     DO YOU HAVE EMERGENCY POWER FOR YOUR RADIO(S)? YES[ ]  NO [ ]
     ARE YOU OWNER/OPERATOR/TRUSTEE OF A VHF/UHF REPEATER? YES[ ]
     IF YES, WHAT ARE THE FREQUENCIES OF THE REPEATER SYSTEM?

     XMIT:____________ RECV:___________ REPEATER CALL SIGN________

     PACKET OR GATEWAY EMAIL ADDRESS(S)___________________________

     _____________________________________________________________
 
 
 
 
 

                            (PAGE TWO)

                AMATEUR RADIO OPERATING CAPABILITIES

     BAND.......CW..SSB..FM..PACKET..BASE...MOBILE..HT..OTHER
     __________________________________________________________
     160 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      80 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      75 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      40 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      30 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      20 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      17 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      15 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      12 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      10 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
       6 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
       2 METER.[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      222 MHZ..[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      440 MHZ..[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
      900 MHZ..[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
     1240 MHZ..[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]
     OTHER BAND[ ]..[ ]..[ ]...[ ]....[ ]....[ ]....[ ]...[ ]

     WHICH OTHER BAND(S)________________________________________

     WHAT OTHER MODE(S)_________________________________________

     MAXIMUM CW SPEED (IF CW CHECKED ABOVE)_____________________

     DO YOU HAVE A 2 METER/440 MHZ DUAL-BAND RADIO WITH CROSSBAND
     REPEAT FUNCTIONS?
     YES[ ]  NO[ ]  IF YES, BASE[ ]  MOBILE[ ]  PORTABLE[ ]  HT[ ]

          DO YOU HAVE ANY HANDICAPS (DISABILITIES) WHICH WOULD
          REQUIRE SPECIAL CONSIDERATION OR ACCOMODATION DURING
          YOUR VOLUNTEER WORK AS A RADIO AMATEUR CIVIL EMERGENCY
          SERVICE VOLUNTEER?    YES[ ]    NO[ ]
          IF YES, PLEASE LIST AND INDICATE ANY REQUIRED SPECIAL
          CONSIDERATIONS OR ACCOMODATIONS:

          ______________________________________________________

          ______________________________________________________

STATEMENT:
It is my understanding that I am applying to be a R.A.C.E.S. volunteer with the Lancaster County Emergency Management Agency and that I will be authorized as a volunteer by the Lancaster County Emergency Management Coordinator. It is acknowledged that as a R.A.C.E.S. volunteer, I may at times be working in a security zone or restricted area. With this in mind, the officials of the Lancaster County Emergency Management Agency (LEMA) may desire to make certain inquires as to my background, character, experience and qualifications. I authorize the Lancaster County Emergency Management Agency to make such inquires as they may deem appropriate of any individual, group, local, state or federal government agency.
     ___________________________________________    ______________
      APPLICANT'S SIGNATURE                              DATE

                 Please submit completed application to:

                 Coordinator, Lancaster County ARES/RACES
                 SPARC, Inc.
                 P.O. BOX   1033
                 Lancaster, PA  17608-1033
                 PHONE: (717) 481-7686 1