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APPLICATION FORM FOR AN INDIVIDUAL FOR A LICENSE TO ESTABLISH, MAINTAIN AND WORK AN AMATEUR WIRELESS TELEGRAPH STATION IN INDIA

(See Rules 6 & 8)

1.Full Name :____________________________________

(In Block Letters)

2.Father/Husband's Name and Address (details of House No.,Street No., Road No.):

____________________________________

____________________________________

____________________________________

____________________________________

3.(a)Address for Correspondence (details of House No., Street No., Road No.):

____________________________________

____________________________________

____________________________________

____________________________________

(b) Permanent Home Address (details of House No., Street No., Road No.):

____________________________________

____________________________________

____________________________________

____________________________________

4.(a) Date of Birth :                     ____________________

(b) Place of Birth :                       __________________________

(c) Nationality :                            __________________________

(d) Occupation :                           __________________________

5.(a) Category of licence applied for:___________________________________

(b) Exact location of the proposed         ___________________________________

       amateur radio station                      ___________________________________

(details of House No.,Street No.,             ____________________________

Road No.)                                                 _________________________________

6. (a) If you are exempted from              _________________________________

appearing in any part of the                    _________________________________

examination, give details of                      _________________________________

your qualifications

(b) If you wish to appear for (a) Centre:_________________________

the qualifying examination, Date/Month:_____________________

give the preferred centre and

date of examination

(c) Do you hold any other

license earlier, if so give details: (i) License No.:_____________________

(ii)Callsign, if any___________________

(Duly filled in application form should be submitted to the concerned Wireless Monitoring Station only)

I hereby solemly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed therefrom. I also agree that in case any information given by me hereinbefore is found false at a later date, the license, if granted, will be cancelled.

I further solemnly give an undertaking that I will not either directly or indirectly divulge to any person, except when lawfully authorized or directed to do so, the purport, of any message which I may transmit or receive by means of any wireless apparatus operated by me or which may come to my knowledge in connection with the operation of said apparatus.

I have carefully read and understood the rules contained in the Indian Wireless Telegraphs (Amateur Service) Rules, 1978 and undertake to abide by them and observe the conditions of the license. The licensed station shall not be made accessible to any unauthorized person at any time.

Signature of witness Signature of Applicant:

Name (in Block Letters) Name (in Block Letters):

Date: Date:

Place:

________________________________________________________________________________________________

The following should accompany the application form:

(ii) Two (2) copies of photograph duly signed on front side. The size of the photograph must be 3x4 cms.

iii) Examination fees in the form of Bank Draft (Rs 25/- for Advanced Grade, Rs 20/- for Grade I, Rs.10/- for Grade II, Rs. 10/- for Restricted Grade and no fees for Shortwave Listeners License) obtained from any branch of State Bank of India and drawn in favour of 'Pay & Accounts Officer (Headquarters), Department of Telecommunications payable at State Bank of India, New Delhi Main Branch (Code No. 0691). An additional fee of Rs.25/- (for Grade I, II, Restricted Grade) and Rs. 50/- for Advanced Grade License is to be submitted in a similar manner after passing the examination.

(iv) The Result Sheet (for applying for the respective license after passing the examination) duly filled (in duplicate).

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