Use the TAB key to move from one field to the next.
Form Instructions
PERSONAL INFORMATION
First Name:
Last Name:
Call Sign:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Pager:
Cell Phone:
E-Mail Address:
Birth Date (mm-dd-yyyy):
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RADIO COMMUNICATION INFORMATION
License Class:
SELECT LICENSE
Novice
Technician
Technician-Plus
General
Advanced
Extra
Primary Radio Interest:
Disaster Service Worker (DSW) coverage? :
DSW Paperwork on file with:
Don't Know
None
City
City Name
Santa Clara County
Check the boxes that correspond to the bands/modes you can operate.
If operating PACKET, the CALL SIGN of your PBBS is:
Can your Home Station Operate without commercial power?
Yes:
No:
If YES, indicate bands:
If you are interested in helping with the local weekly Net, Check here:
If you are interested in helping with the National Traffic System (NTS) Net, Check here:
...And FINALLY
Select the City/Emergency Coordinator (EC) to receive this registration.
When you select an EC and then click on SUBMIT, you will get a screen
that shows you what you have entered, and you will have the chance to
Submit that, or go BACK and correct it. If you have provided an E-Mail
address, you will be sent a copy of the information you provided.
This information will only be used for ARES/RACES activities and will
NOT be shared with outsiders without your permission.
SELECT CITY/EC
Campbell, Barton Smith, N6HDN
Cupertino, Jim Oberhofer, KN6PE
Gilroy, Pat Moore, K6PMM
Loma Prieta, Dan Pugh, KM6GNG
Los Altos, Jim Clark, N6JRC
Los Altos Hills, Neil Katin, K2LL
Los Gatos/Monte Sereno, Patrick Dirks, N6PWD
Milpitas, Paul Ellis, KM6IAO
Morgan Hill, Gary Goelkel, K6GMG
Mountain View, Leslie Grimm, KK6EKN
NASA-Ames, Mark Allard, KD6CWM
Palo Alto, Walter Underwood, K6WRU
San Jose, Nigel Gore, AF6ZFM
Santa Clara, Bill Rainey, K6WAR
Saratoga, Peter Melhus, AA6PM
Stanford, Lea Roberts, WA6ITV
Sunnyvale, Wolfgang Polak, AI6SL