CHAPTER BORINAGE APPLICATION FORM
Calling for the Basic Certificate
This form to be sent to:
Claude DEMAN (ON4CN)
Pavé de Warquignies, 119
B-7340 Warquignies
Belgium (Europe)
STATION IDENTIFICATION


Call sign : ...........................

10-X : # ............................

Name : .............................

First name : ..............................

Address : ...............................

ZIP code : ..............................

City : .................................

Country : ..............................

Contacts made with : .........................

Stations : ............................

Date : ..............................

Points : ................................

STATION IDENTIFICATION

1-..................................................................................................................................

2-..................................................................................................................................

3-..................................................................................................................................

4-..................................................................................................................................

5-..................................................................................................................................

6-..................................................................................................................................

7-..................................................................................................................................

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9-..................................................................................................................................

10-..................................................................................................................................

I send along with this application form a SAE and 6 Dollars or 8 euros for the return.

Signature

Pour m'écrire : claude@on4cn.org
Dernière mise à jour: 22/06/2002
Statistique Chapter Borinage