Jennings County Amateur Radio Assn. Inc. Member Information

Please complete this form, and scan/send/give to Gene Dolgner KC9RLC or email to
kc9tme@gmail.com or mail to Randy Poynter 2501 Newburg Road, Louisville K.Y. 40205

Name:

Call Sign:

License Class:

Address:

Birth: Day:

Month:

City:

State:

Zip:

County:

Home Phone:

Cell Phone:

Work Phone:

Text(Y/N):

Email 1:

Email 2:

Any Physical Limitations:

Emergency Contact: Name:

Phone 1:

Phone 2:

Address:

City:

State:

Zip:

What Amateur Radio capabilities do you have?

Mode/Meter

70cm 420

1.25M 222

2M 144

6M 50

10M 28

12M 24.9

15M 21

17M 18

20M 14

30M 10

40M 7

60M 5.3

80M 3.5

160M 1.8

CW

AM/SSB

FM

SSTV

PSK 31

Packet

APRS

Mobile

Port/HT

Base Ant.

Mobile Ant.

Emer. Power

Specialized Training (SKYWARN, Red Cross, National Incident Management System (NIMS)

Interested in ARES? (Y/N):

Interested in RACES? (Y/N):

ARRL Member? (Y/N):

ARRL Member #:

Applicant Signature:

Date:

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For club use only: Dues Paid:  2016 2017 2018 2019 2020 2021 2022 2023