Hospital Amateur Radio Nettwork

Sponsored by STARRS (St. Louis Regional Response System)

Application Form

Last Name:
First Name:
Amateur Callsign:
Amateur License Class:
Amateur License Expiration Date:
Have you completed either the ARECC (level 1) or the IEC course?	ARECC = Amateur Radio Emergency Communication Course IEC = Introduction to Emergency Communication No Yes
Home Address:
City, State, Zip code:
Home phone number:
Work phone number:
Mobile phone number:
Pager:
E-mail address (1):
E-mail address (2):
1st Hospital Choice:
2nd Hospital Choice:
3rd Hospital Choice: