Last Name

First name

Middle

DOB

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Preferred Contact Phone
 Home  Work  Cell

TEXT To Cell
 Yes    No

Personal e-mail address

Work / School e-mail address}

Preferred e-mail Forwarding
  Personal e-mail       Work / School e-mail

Select One
  Employed       Retired     Student

Amateur / GMRS Call Sign (if applicable)

License Class (if applicable)

License Expiration (if applicable)

FCC Licensee Holders Only

Please describe your ability to operate off the commercial power grid.

MODE

MOBILE

HOME

PORTABLE

HF

 

 

 

VHF

 

 

 

DIGITAL

 

 

 

In the space provided please detail any special capabilities you have that may be helpful when deploying resources Example: 4WD, portable generators, portable antennas or other information that you believe may be helpful.

Training, Certification, Qualifications or Special interest. Include such items as NIMS classes, Emergency Management institute Courses, ARRL Courses, Red Cross Training, CERT, SKYWARN, etc.

Statement on the Radio Amateur Civil Emergency Service

The Baltimore County Auxiliary of the Mayland Auxiliary Communication Service is registered with and  administered by the Office of Homeland Security and Emergency Management (OHSEM). When activated by OHSEM during natural or man made disasters the Auxiliary Communication Service deploys as a volunteer Emergency Communications unit operating as Radio Amateur Civil Emergency Service (RACES) personnel.  Properly: “RACES is administered by the tribal, local or state government agency responsible for Civil Defense that adopts a RACES plan, appoints a Radio Communications Officer, and establishes a unit that operates according to Part 97 97.401, 97.403, 97.405 and 97.407 of the Communications Act of 1934, as amended by the Telecommunications Act of 1996.

PARTICIPANT AGREEMENT

I hereby apply for a volunteer position with the Baltimore County Auxiliary of the Maryland Auxiliary Communications Service, a 501(c)3 non-profit, and agree to comply with the guidelines set forth in the Auxiliary Communications Service Standard Operating Plan (SOP) as approved by the jurisdiction's Office of Homeland Security and Emergency Management. I will be an active participant in monthly drills, training, field exercises, and emergency deployments. I agree to complete EMERGENCY COMMUNICATOR TRAINING as defined in the ACS SOP and the ACS website. I understand that I serve at the pleasure of the Director and Auxiliary Communications Service Officer and I understand that my appointment will be reviewed every 2 years for continued participation in the jurisdiction's program. I further understand that in enrolling with the Baltimore County Auxiliary of the Maryland Auxiliary Communications Service I am secondarily enrolling as a volunteer under the ARRL ARES program for the served jurisdiction. To maintain active status I agree to a minimum participation of 26 hours per year. I understand and agree that participation Credit is applied to my total hours for time allocated to formal training, weekly nets, monthly deployment exercises, self-study Emergency Management Institute (EMI) courses, meetings, public service, activations, and equipment maintenance. I further understand in order to receive credit my hours must be recorded electronically via the organization's website and approved by a Team Leader (TL), Deputy Auxiliary Communication Office (DACO) or the Auxiliary Communication Officer (ACO).

I agree to and acknowledge acceptance of the above participation requirement and I certify that: (1) If I possess a current and valid FCC radio License, the license has never been suspended or revoked; (2) I have never been denied acceptance into, nor had participation revoked, in another emergency communications program; (3) I have never been convicted of a felony; (4) I am a citizen of the United States; (5) I am physically and mentally able to perform the duties of the position applied for with the Auxiliary; (6) I may be granted access to secure facilities, therefore, prior to receiving my credentials, I may be subject to a background check to verify information provided on this enrollment form.

I, the undersigned, do hereby declare that the above information is, to the best of my knowledge true and correct.

 


Signature (Enter your full name as above)


Date Signed

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