HAM Radio - Disaster Support Registration

First Name * Last Name Call Sign (or "SWL") * ASOC License Number License Valid Uptil [dd-MMM-yyyy] Residence Phone No * Mobile Number * Other Contact No Email Address (Primary) * Alternative Email Address Residence Area * Residence (MCGM) Ward * Complete Residence Address * Office Phone No Office Area Office (MCGM) Ward Names of Amateur Radio Societies you are attached to (1 per line) Allergies to any substance or medicine Details of any illness or disease (like High BP / Asthama / Bronchitis / Diabetes) Mention illness - medication - location of medication Emergency Contact Numbers - Relation to you * Do you know how to swim? * Yes No My current commitment level to disaster support * -Select-10% - not very committed20%30%40% - may be committed50%60% - depends on circumstances70%80%90%100% - will definitely support 3 Hams Closest to Morning QTH (1 per line) * 3 Hams Closest to Home QTH (1 per line) * No of VHF Handies / Walkie Talkies * -Select-012345678910more than 10 No of VHF Base Stations * -Select-012345678910more than 10 Location of VHF or UHF Base Stations (1 per line) No of HF Base Stations * -Select-012345more than 5 Location of HF Base Stations (1 per line) Type of Antenna(s) - And Location (1 entry per line) No of Power Supply Units * -Select-012345more than 5 Location of Power Supply Units (1 per line) Battery Backup at Base Stations? Yes No Battery Amp rating and Voltage (if Yes) Setup Ready for Communication from Morning QTH? Base Station Ready Handies Ready Antenna Ready Setup Ready for Communication from Home QTH? Base Station Ready Handies Ready Antenna Ready Setup Ready for Communication from Car/Bike/Mobile QTH? Base Station Ready Handies Ready Antenna Ready Declaration: I, the above mentioned, wish to confirm that the above mentioned information I have provided is true and complete to my knowledge and belief in all respects. I am joining the disaster communications team at my own free will, with my free consent and without any fraud, coercion, misrepresentation or undue influence and agree to bear such risk at my own cost. I understand and accept all the consequences of being a part of the disaster communications team and will not hold any person responsible or liable for the consequences arising out of and in the course of any disaster or mishap whatsoever. Declaration * Yes, I agree No, I Dont Agree Upload Passport Size Photograph Signature (Type in your FULL NAME) * Verification Code (enter the characters you see in the above picture) View Error Details   Powered by