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2. Community Emergency Response Team (CERT)/ Radio Amateur Civil Emergency Service (RACES) Volunteers Application
   Please fill out below required fields.
4. First Name*
5. Middle Name*
6. Last Name*
8. Physical Address*
10. Mailing Address (if different)
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Email Address
19. Social Security Number*
20. Drivers License Number*
21. State of License*
23. Date of Birth*
    Date of Birth
27. Please fill out below only if applying for CERT
29. CERT I.D. Number
    If you do not have one yet, use CERT123
30. Location of Training
    Use the town where you were trained.
31. Training Completion Date
    Training Completion Date
    The last day of training.
35. Please fill out below only if applying for RACES
37. Call Sign
38. Type of Amateur License
39. How long have you been an operator?
41. Physical Location of your station
43. City
44. State
45. Zip
47. Do you currently or have you ever been a member of a RACES Unit

    1. Yes
    2. No
48. If yes, where, when, and how long
50. Have you ever been active in an emergency as an Amateur Radio Operator?

    1. Yes
    2. No
51. Have you taken any NIMS training?

    1. Yes
    2. No
53. Please list any NIMS completed training
57. By checking this box, you acknowledge that volunteers for Queen Anne's County Department of Emergency Services are subject to a background investigation and vetting process.*

    1. I understand
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field