SRV HAMS Contact / Capabilities Survey

This form is intended for use by Amateur Radio Operators residing or working in the Santa Rosa Valley community of Ventura County who are interested in participating in a community emergency communications group. Any other submissions will be discarded.

Please complete the following questionaire supplying all of the information you can. You may also use this form to report changes in information previously supplied.

Information supplied on this form is strictly for the purpose of organizing activities of mutual interest and will not be provided or sold to any other group or individual without your express permission.

* Required Information  
  Version 2.01 Personal Data
* Amateur Callsign:
  License Class: Extra Advanced General Tech Plus
Technician Novice
* eMail Address:
* Last Name:
* First Name:
  Middle Initial:
  Nick Name:
* Is this an update to a prior Registration? Yes
No
  Mailing Address:
  City:
  State:
  Zip Code:
  Telephone
Numbers:		 Home:
Work: Ext:
Mobile/Cell:
FAX:
Pager:
  Primary Frequency Monitored: MHz.
  Employment: Employer:
City:
eMail:
  Preferred
Method
of
Contact:		 Home Telephone
Mobile/Cell Telephone
Pager
Work Telephone
Other:
  Notify in Emergency: Name:
Telephone Number(s):
Relationship:
  Do you have any Special Medical Condition? No
Yes - Explain
 
    Equipment Availability
Check only equipment in operting condition
  Home (Fixed) Station; 75-10 Meters
6 Meters
2 Meters
222 MHz
440 MHz
1.2 GHz
ATV
CB 11 Meters
GMRS
Family Radio Service
MURS
Other
  Mobile (Installed or Portable): 75-10 Meters
6 Meters
2 Meters
222 MHz
440 MHz
1.2 GHz
ATV
CB 11 Meters
GMRS
Family Radio Service
MURS
Other
  Handheld: 6 Meters
2 Meters
222 MHz
440 MHz
1.2 GHz
GMRS
Family Radio Service
MURS
Other
  Emergency Power: Home Generator KW
Portable Generator KW
Portable 12V Battery
Other KW
  Portable Antennas: HF: HF Vert HF Beam HF Wire Ant
- Bands
6M: Vert Beam
2M: Vert Beam
222MHz: Vert Beam
440MHz: Vert Beam
1.2GHz: Vert Beam
Other: (Describe)
 
    Experience
Please indicate if you are a member of another emergency services organization or have related experience.
  Do you belong to ACS, ARES, or RACES? No
Yes - Please provide details
  Have you completed the Ventura County CERT Training? No
Yes
  Please list any additional skills here:
(If GMRS checked above, please list License.)
 
 
Other Comments:
 
  Do you want to be included on the SRV_HAMS ONLY eMail Reflector so you can stay informed about our actitivities? Yes
No
  Do you want to participate in the Santa Rosa Valley Emergency Radio Network (SRV-ERN)? Yes - You will be subscribed to the SRV-ERN List.
No
  If you would like to participate in the SRV-ERN Text Message Alerting System please provide the requested information. SMS Text Capable Telephone Number:
Provider (select one):
AT&T
T-Mobile
Sprint
Verizon Wireless
Other-Please provide name