BackMembership Application Form
* Full Name
* Call Sign
* E-mail

* Required Field


 

* Required Field

Full Name    * Call Sign   
Street Address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
*  Required Field



Age       Sex:     Male   Female




Have You Ever Received a Notice of Violation from the FCC:
Yes       No

If "yes", explain

 




Organizations you belong to:
ARRL     MARS     ARES     RACES




Have you ever worked with us before?
Yes     No

If "Yes", Please describe when / how you participated?

 




Do you speak any foreign languages?
Yes     No

If "Yes", Please list and how proficient you are.

 




Bands and Modes Operate:

 




Radio/Computer Equipment

 




Nets you frequent

 




Sources of Weather Information

 




Days/Hours Available

 




Education
High School     College     Advanced Degree




Please provide information indicating why you wish to belong to the HWN,
why you feel you have the requested qualifications, and what your level of
commitment will be.


 



Be sure you have completed all the required fields (above) before pressing the "submit button".

 

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