ECRV 4712 Class Registration

ECRV 4712 Operator - Class Registration

Please complete the following application. If you're missing any of the prerequisits (*), explaine your anticipated completion in the "Questions" section.

Personal Information:

Name:

First: Last:

Street Address:

P.O. Box:

(If Applicable)

City:

State:

Zip Code:

E-mail:

Home Phone:

Cell Phone:

Other Phone:

Best time to call:

Red Cross
Chapter Affiliation:

DSHR #:

Primary Group & Activity
(If DSHR Member):

Secondary Group & Activity
(If DSHR Member):

CPR
Expiration Date:

* 1 Year

First Aid
Expiration Date:

* 3 Years

Defensive Driving
Expiration Date:

* 3 Years

Amateur Radio
(Desired, Not
Required):

Call Sign: Class:

Deployment Information:

I can deploy on a
National Disaster
during 2008 for
(Required Field):

1 Week 2 Weeks 3 Weeks

Training Information:

I prefer
ECRV training
(Required Field):

Week Days Only Week Ends Only
Either Week Days or Week Ends

Qualifications:

Summarize skills, such as, computer, networking experience, and qualifications that may help you work with the ECRV.

Questions:

Do you have any questions concerning your working with the ECRV?

A copy of this application with be send to the above e-mail address.