MARS Membership Application Form

;	UNITED STATES AIR FORCE MILITARY AUXILIARY RADIO SYSTEM (MARS) NORTH CENTRAL DIVISION MEMBERSHIP APPLICATION

NEW

RENEWAL
(FCC License change)

TRANSFER

UPDATE INFO
(Personal or Station Capability)

REINSTATE

* denotes required fields

NAME

Last*

First*

Middle

Preferred Nickname

STREET

Street Address*

CITY

City*

State*

ZIP+4 Code*

County*

Date of Birth (Must be 18 or older) (mm/dd/yyyy)*

TELEPHONE


Home phone*	Business phone	Cell	Fax	DSN

EMAIL ADDRESS

CURRENT or PREVIOUS MARS SERVICE (if any)		MARS CALLSIGN
		(Use current Callsign if renewing)

HAM CALLSIGN*		CLASS*		EXPIRATION*
					mm/dd/yyyy

Station Capabilities

New applicants must have equipment that meets USAF MARS specifications for stability and purity of emission operating SSB on at least 2 of the North Central Division MARS frequencies and have the capability to operate on at least one digital mode. See elegibility requirements.

ASSIGNED		HF 3308 KHz	COMPUTER
	ALE	HF 4517 KHz		IBM
	Patch	HF 7305 KHz		APPLE
	PMBO	AMP		LINUX
	FEMA	VHF		NO PC
	BST	GENERATOR	DIGITAL MODES
	SHARES	DEPLOYABLE HF		RTTY		PACKET
Entered SHARES		DEPLOYABLE VHF		AMTOR		PSK31
Entered SHARES		DEPLOYABLE DIGITAL		PACTOR		MT63
				G-TOR		MFSK16
				CLOVER		SSTV
	NTIA				NO DIGITAL

Emergency Communications Training

		FEMA 100		FEMA 200		FEMA 700		FEMA 800
Date Completed
	mm/dd/yyyy		mm/dd/yyyy		mm/dd/yyyy		mm/dd/yyyy

ARRL		ECOMM1		ECOMM2		ECOMM3

PRIVACY STATEMENT

Privacy Act of 1974--Under the authority of 5 USC 301 and 10 USC 133, the information requested on the Air Force MARS Application for Membership is for the purpose of establishing, renewal or modification of MARS membership. The form is maintained as official Air Force MARS records. The information on this form will not be divulged without your written consent. Disclosure of the information requested on this form is voluntary. Failure to provide this requested information may result in disapproval of the application or delays resulting from additional research required to establish satisfactory eligibility.

GENERAL RELEASE -In considerartion of the permission extended to me by the United States through its officers and agents to engage in activities of the Military Auxiliary Radio System, I do hereby, for myself, my heirs, executors and the administrators, remise, release and forever discharge the government of the United States, its officers, agents and employees, acting officially or otherwise, from any and all claims, demands, actions or cause of action, on account of damage to property and personal injuries, or death, suffered by me directly or indirectly resulting from my participation in the activities of the Military Auxiliary Radio System. I certify that I will abide by all the governing rules and regulations now or hereafter prescribed by the Department of Defense for the Military Auxiliary Radio System. (This release is not intended to apply and shall not be construed to apply to statutory rights of personnel in the military service, nor to any other rights of individuals under policies of life insurance (E.G. NSLI) or other forms of contracts with the United States.)

Signature of Applicant*#

#Your typed signature indicates your willingness to abide by the rules and regulations of the USAF MARS program and that you attest that the inforntion on this form is accurate and correct to the best of your knowledge. Providing false or misleading information may violate federal statute and may be punishable by fine and/or imprisonment. Information provided may be verified prior to processing of this application.