Amateur Radio Emergency Service 
Radio Amateur Civil
Emergency Service
Name:
_________________________________________ Call: _______________ License Class:_________
Address: _________________________________________________________________________________
City:
______________________________________ State: ____________ Zip Code:
_____________________
Home Phone:
__________________Business Phone: _________________ Cell/Pager: __________________
License Class:
_________________ Primary Radio Interests:
_______________________________________
Other Professional
Licenses or Certifications: ___________________________________________________
Email address: _____________________________________________________________________________
Check bands and modes
you can operate:
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Band |
160 |
80 |
60 |
40 |
30 |
20 |
17 |
15 |
12 |
10 |
6 |
2 |
222 |
440 |
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FM |
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RTTY |
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SSB |
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MOBILE |
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PACKET |
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PORTABLE |
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Which
of the following items are available to you?
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Reliable
transportation |
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Portable
battery power |
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4
wheel drive vehicle |
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Portable
generator |
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RV
trailer or motor home |
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Have
you completed: ICS-100___ ICS-200___ ICS-300___
ICS-700___ ICS-800____
(ICS-100 through ICS-700
required for basic state certification.)
What
other ICS training and certification have you received?
_______________________________________________
Describe
any disaster experiences you have had. _________________________________________________________
What
disaster training have you had?___________________________________________________________________
Do you hold a current first aid card? YES_____ NO _____
The following information is required by the
Oregon Emergency Management Department, to obtain a state ARES/RACES photo ID
card. This card
is mandatory to be able gain entry to secure emergency facilities such as the
EOC, 911, Fire and Police stations or disaster sites for providing auxiliary
radio communications. All
information is strictly confidential and is for the purpose of the mandatory
background check conducted by the Sheriff’s Office. Columbia County and the State of
Oregon is dual ARES and RACES membership. All information will be carefully
guarded and not used for any other purpose than a background check for a State
of Oregon identification card.
Full legal name:
_____________________________________________ Call sign: ___________________
Date of Birth: __________________ ODL or ID
#___________________
Hair Color: _____________ Eyes: ____________
Height: __________ Weight: ________lbs
DPSST#:_________________________ ARES/RACES Identification
Card Number: ______
(Public safety personnel only) (If any)
Signature:
________________________________________________________ Date: ________________
Please mail to David Morrisson, Columbia
County ARES/RACES, 58605 Kavanaugh, St., Helens, OR 97051
or
email form to: w7or@arrl.net.
A
downloadable form is available at http://www.colemer.org/ARES.htm