-O- Calling for the Basic Certificate

-O- Calling for an UPGRADE

-O- Calling for the EXTRA Certificate

-O- Calling for the SUPER Certificate

STATION IDENTIFICATION

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

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

Last name : ..............................

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

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

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

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

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

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

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

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

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

STATIONS CONTACTED

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

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

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

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

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

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

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

8 - .......................................................................................................................................................

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

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

I send with this application form :
-O- a SAE.
-O- 3 USD or equivalent in EUR for the mailing costs (UPGRADE - EXTRA - SUPER)
-O- 6 USD or equivalent in EUR for the mailing costs (BASIC)

Signature