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 ____________________
(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):
The following should accompany the application form:
(i) Nationality Certificate/ Character Certificate.
(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
(iv) The Result Sheet (for applying for the
respective license after passing
the examination) duly filled (in duplicate).
(v) Personal particulars (in quadriplicate) in the prescribed proforma.