Lycoming County ARES Registration Form

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Name *

Call Sign *

Address 1 *

Address 2

City *

State

Other:

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Zip

Home Phone *

Work Phone

Cell Phone

E-Mail Address

License Class: *

Tech

General

Extra

Other:

Band that you can operate

Please Check All That Apply

6 Meters

2 Meters

222 Mhz

440 Mhz

Other:

HF Modes that you can operate

Please Check All That Apply

SSB

Data

Packet

Other:

VHF/UHF Modes that you can operate

Please Check All That Apply

SSB

Data

Packet

Other:

Do you have backup power?

Yes

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I have the following NIMS certifications

ICS-100

ICS-200

ICS-300

ICS-400

ICS-700

ICS-800

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