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 Gene Dolgner  
5775 North State Highway 7 Scipio, IN 47273 

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:


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