________________________________ Date: ___________
________________________________
To: _____________________________
________________________________
________________________________
Application for:________________________________________________
Awards fee enclosed: ____________________
The information and/or the QSLs required for this award have been checked and are certified to be correct by the following radio amateurs:
_________________________ _________________________
Signature Call Signature Call
"I declare that all the necessary credits for this award have been obtained in accordance with the rules for the award, as well as the rules and regulations for radio amateurs in my country. Please accept this information and send the award to my QTH as listed above."
Applicants Signature: ______________________________________Date: ______________
| Number | Call | Date | Time | Band | Mode | RST | Other |