Potter Co. ARES Application
Amateur Radio Emergency Services (ARES®)
Potter Co. ARES® Group (PC-ARES)
Additional Member Application Information
ALL INFORMATION IS HELD CONFIDENTIAL AND WILL NOT BE USED BEYOND ARES®
Applicant Name: _________________________________ Call Sign: _______________
Home Station Address: ____________________________________________________
Home Station Latitude: ____°____' ____" W. Longitude: ____°____' ____" N.
(you can look this up at: www.QRZ.com under your call sign information)
Are you SkyWARN trained and certified? No [ ] Yes [ ] Date: ____/_____/20____
Have you had any Civil Emergency Response Team (CERT) Training ? No [ ] Yes [ ]
If so, through which Municipality/Organization? _______________________________
Have you had Red Cross CPR/First Aid training? No [ ] Yes [ ] Date: ___/____/20____
Have you taken any ARRL ARECC (Amateur Radio Emergency Communications Courses)?
[ ] No [ ] EC-01 [ ] EC-02 [ ] EC-03
Course information is available at: www.arrl.org/online-course-catalog
Have you taken any FEMA Independent Study Program ICS Courses?
[ ] None No online FEMA coursework taken (yet)
[ ] ICS-22 Are You Ready? An In-depth Guide to Citizen Preparedness
[ ] ICS-100a Introduction to the Incident Command System
[ ] ICS-200a ICS for Single Resources and Initial Action Incidents
[ ] ICS-317 Introduction to Community Emergency Response Teams (CERT)
[ ] ICS-700a National Incident Management System (NIMS) - An Introduction
[ ] ICS-800b National Response Framework - An Introduction
You can request a FEMA course transcript at this link:
Are you a member of the ARRL? [ ] No [ ] Yes
If so, are you an ARRL Official in any capacity? [ ] No [ ] Yes______________________
Do you have any National Traffic System (NTS) or Traffic Handling experience? [ ] No [ ] Yes
Do you have experience as a Net Control Operator for any net, formal or informal?
[ ] No [ ] Yes If so, which net(s)? _________________________________________
Are you a RACES volunteer operator? [ ] No [ ] Yes
Are you a Salvation Army Team Emerg. Radio Net (SATERN) operator? [ ] No [ ] Yes
Do you have any Digital Radio experience? [ ] None
[ ] NBEMS - Fldigi Modes [ ] Packet [ ] Fax [ ] RTTY
Do you have any Amateur Television (ATV) experience (SSTV or FSTV)? [ ] No [ ] Yes
Can you operate CW (morse code)? [ ] No [ ] Yes Approximate Speed _______ WPM
Do you have any Citizens Band (CB), Family Radio Service (FRS) or General Mobile Radio Service (GMRS) radio equipment? [ ] None [ ] CB [ ] FRS [ ] GMRS
Do you have any Satellite capable equipment and antennas? [ ] No [ ] Yes
Are you a member or volunteer in any of these organizations/service agancies?
[ ] Civil Air Patrol (CAP)
[ ] Military Affiliated Radio Service (MARS) [ ] Army [ ] Air Force
[ ] US Coast Guard Auxiliary (USCGAUX)
[ ] American Red Cross
[ ] Salvation Army (SA)
[ ] Any Fire Department, Rescue/EMT Squad or Search & Rescue Unit _______________
[ ] None
Other than your ham ticket, do you hold any other FCC licenses or permits?
[ ] No [ ] Yes If so, please give your call sign or permit type ____________________
Any other information pertainent or important to this application, please list here:
Chautauqua Emergency Coordinator
Gilbert "Skip" Kauffman - K3CC
121 Niles Hill Rd.
Coudersport, PA 16915
Submission of this application does NOT guarantee acceptance into PC-ARES or ARES®