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From: ___________________________

________________________________                   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: ______________


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