EMERGENCY RADIO SERVICE

PO Box 545

PASADENA CALIFORNIA 91107

APPLICATION FOR ERS MEMBERSHIP

I am requesting.( ) Active ( ) Associate membership.		Date
Name, First	Name, Last
Home Phone	Work Phone
Pager number / Pin	Fax number
Address		Apt. #
City	State	Zip
e-mail (Optional)
Occupation
Work Address (Optional)
City	State	Zip
( ) Male / ( ) Female (Optional)	DOB
Emergency Contact Phone Number	Name	Relation
1
2
Do you have any radio experience? ( ) Yes ( ) No
If so what kind?
Do you own any radios? ( ) Yes ( ) No
If so what kind?
Are you affiliated with any other organizations?
If so which ones?
Reason for wanting to join the ERS ( attach additional sheet if required)
Applicant Signature		Date
For Active Membership Applications Only, Sponsoring Member ( Must Be An ERS Member In Good standing)
Name	Signature	Unit Id #
1
2

Print this form and mail in.