SRV-ERN Registration

This form is intended for use by Santa Rosa Valley residents and business owners who are interested in participating in a community emergency communications network. 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.

If you are a licensed Amateur Radio Operator, do not complete this form. Click Here for a special form for Hams.

* Required Information  
  Version 0.03 Personal Data
* eMail Address:
* Last Name:
* First Name:
  Middle Initial:
  Nick Name:
* Is this an update to a prior Registration? Yes
No
* Address:
* City:
* State:
* Zip Code:
  Telephone
Numbers:		 Home:
Work: Ext:
Mobile/Cell:
FAX:
Pager:
  Employment: Employer:
City:
eMail:
  Preferred
Method
of
Contact:		 Home Telephone
Mobile/Cell Telephone
Pager
Work Telephone
Other:
 
    Radio Equipment Availability
Check only equipment in operting condition
  Home (Fixed) Station; CB 11 Meters
GMRS
Family Radio Service
MURS
Other
  Mobile (Installed or Portable): CB 11 Meters
GMRS
Family Radio Service
MURS
Other
  Handheld: GMRS
Family Radio Service
MURS
Other
  Emergency Power: Home Generator KW
Portable Generator KW
Portable 12V Battery
Other KW
 
  Have you completed the Ventura County CERT Training? No
Yes
  Please list any applicable special skills here:
(If GMRS checked above, please list License.)
 
 
Other Comments:
 
  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