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)
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:
E-mail address (1):
E-mail address (2):
1st Hospital Choice:
2nd Hospital Choice:
3rd Hospital Choice:

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