Presidential Counties Award Application

Eastern Amateur Radio Society

We respect your privacy! Information provided on this application and attachments will be used solely for the purpose of issuing your award certificate. It will not be sold, shared, or circulated in any way what so ever. You will not be put on any type of mailing list either.

Personal Information

Name______________________________________________ Date_____________

(As it is to appear on your certificate)

Address______________________________________________________________

City___________________________ St / Province _______ Zip_________________

Call Sign____________________________ License Class______________________

I certify that I have QSL cards in my possession for all contacts listed on the attached log extract. I am willing to send any QSL cards that may be

requested with a self-addressed postage attached envelope for their return

Signature______________________________________________________________________

Award Information

Number of Presidential-Counties Confirmed_______

[ ] Basic Award for 43 Counties ( no endorsements of any type mixed band and mode)

[ ] All one band ____________ Single Mode [ ] SSB [ ] CW [ ] Digital

[ ] Other endorsements i.e. QRP, Solar Power, Mobile, etc.___________________________________

Field Review Committee

I certify that the information in this application and attached log extract is true and accurate. I further state that I have operating privileges equal to or higher of those of the applicant; I have reviewed the QSL cards to my satisfaction. I am aware that additional documentation may or may not be requested. If further proof is not requested, an award certificate will be issued based upon my review and signature.

Signed _______________________________________________ Call Sign ______________________

Signed _______________________________________________ Call Sign ______________________

Committee Review

[ ]App Complete [ ] Log Reviewed [ ]Endorsement Request Reviewed

Special Notes ________________________________________________________

____________________________________________________________________

Approved by____________________________

Certificate Printed ________________ Mailed _______________

Mail to: Eastern Amateur Radio Society 144 Allen Douglas Dr. Richmond, KY 40475

Check payable to: Eastern Amateur Radio Society

Log Extract Verification

The verification process is very simple. Your log extract will be inspected by two hams (of your choice) with a license class equal to or higher than your license class. This process is called “Field Review”. The two individuals must certify that the information on the application is true and that they have examined your QSL cards to their satisfaction for the review process.

On your application, you only need to fill in the top two portions. These are the “Personal Information” and the “Award Information” section.

Your “Field Review Committee” will fill in their section only.

The last section, “Committee Review” is to be completed during our review process. During this time if our Awards Manager may or may not request photo copies of selected cards. Any photocopies submitted as proof will remain here in your file.