Potter Co. ARES Application

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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®

 

Date: ____/_____/20___

 

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____

Certification No.:________________

 

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:

http://training.fema.gov/EM/Web/downloads/tranrqst1.pdf

 

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

email: k3cc@verizon.net                                                                   

 

Submission of this application does NOT guarantee acceptance into PC-ARES or ARES®