WICEN  S.A  Inc.  UPDATE  FORM
 For Update of Membership and/or Equipment details

All details are optional - however the more that you complete, the less times we will have to phone you to verify the information that you have provided

(If you are concerned about security or privacy issues, then please follow the instructions at the end of this page).
Applicant Details:
Your Name: Contact Address   
Date of Birth:
Home Phone Number: Work Phone Number:  
Mobile Phone Number: Fax Number:  
Email Address: Packet Address:  
Contact Person (Family member or etc): Their Phone Number:  
Contact Times: At Work Home ONLY Either method
Employer:
Medical & Related data:
Specific Conditions / Medication: Special Physical Requirements:  
Special Skills:
Special Skills / Talents: Special Licences - i.e Heavy Truck etc:  
Communications Capabilities:
Amateur Callsign:
H.F: H.F Mobile:   H.F Portable: H.F Base    :
10M-FM: 10FM Mobile: 10FM H-H / Portable: 10FM Base:
6 Metres: 6M Mobile:    6M H-H / Portable:    6M Base:   
2 Metres: 2M Mobile:    2M H-H / Portable:    2M Base:   
70Cm: 70Cm Mobile: 70Cm H-H / Portable: 70Cm Base:
Other Comms: UHFCB Mobile: UHFCB Base: UHFCB H-H / Portable:
  HFCB Mobile:  HFCB Base:  HFCB H-H / Portable:  
Other Services: RFDS / VKS737 Mobile:
RFDS Callsign: VKS737 Callsign:
Masting - Portable:
Portable Antenna Systems:
Packet Radio:
Packet Radio - 1 H.F Home   2M Home  70Cm Home  
Packet Radio - 2 H.F Mobile 2M Mobile 70Cm Mobile 
Packet Radio - 3 H.F Portable 2M Portable 70Cm Portable
Packet Radio - 4
Other Equipment: Equipment Comments:  
Your Vehicle Details:
Make - Model: Registration Number:  
Colour: Seating Driver +
Type of Vehicle Fuel Type
Transmission 4-W.D 2-W.D
Auxillary Power: 240V Alternator: 240+12V: Solar Panel(s):
Your Availability:
Any Final Comments:


WICEN S.A Inc. Membership / Details Update form.

If you do not wish to forward details electronically, then you may
print out a copy of this page and post it to..

Attention: Secretary, WICEN S.A Inc, P.O. Box 1080, Stirling, SA, 5152. 

(This page Last Modified on : 06/10/2005 )