The form below may be reproduced and filled out by the applicant for any level of USA-CA. 

USA-CA APPLICATION FORM

 
Date:
Name:
Callsign:
Street Address:
City or Town:
State/Country/Postal Code:
The above named person hereby applies for USA-CA Class: __________________ for confirmed contacts with __________ different US counties representing ______states and for special band or mode endorsement as follows: __________________________________.
(State if operations were mixed band/mode or otherwise).
I certify that I have the QSL cards in my possession for all contacts listed in the Record Book or listing provided with this application and that the municipalities named therein are within the counties listed.  I am willing to send any specified QSL cards as may be requested, together with return postage for same via registered mail (or first class, at my option).  I also understand that this record book or listing becomes the permanent property of the CQ USA-CA Custodian and will not be returned.
Full signature of applicant: _________________________________________________

USE THE FORM BELOW FOR WITNESS CERTIFICATION:

USA-CA CERTIFICATION FORM
The undersigned certify upon their honor that the QSL cards for the contacts listed in the preceding pages or listing are in the possession of the applicant and have been sighted and checked for validity.

WITNESS #1

Date: __________________

____________________________________
Signature and Call

____________________________________
Organization, if any, and title

____________________________________
Address

____________________________________
City/State/Country/Postal Code

WITNESS #2

Date: __________________

____________________________________
Signature and Call

____________________________________
Organization, if any, and title

____________________________________
Address

____________________________________
City/State/Country/Postal Code

(Note: Certification officials must be either two licensed amateurs holding General Class or above licences, or officials of a national level radio organization or affiliated club.)

 

or you may use this PDF file:

 

The application consisting of the county listing and certification shown above should be mailed to:

Ted Melinosky K1BV
USA-CA Custodian
12 Wells Woods Road
Columbia, Connecticut 06237

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