APPLICATION FORM FOR AN INDIVIDUAL FOR A LICENCE TO ESTABLISH

MAINTAIN AND WORK AN AMATEUR WIRELESSS TELEGRAPH STATION

IN INDIA

(  See rules 6 & 8  )

1. Full Name :

2. Father/Husband's Name and :

    Address (Please give details of

    House No., Street., Road No., etc.) :

3. Address for Correspondence :

    (Please give details of House No.,

    Street No., Road No., etc.,)

    Permanent for Correspondence :

    (Please give details of House No.,

    Street No., Road., etc.)

4. Date of Birth :

    Place of Birth :

    Nationality :

    Occupation :

5. Category of Licence applied for :

    Exact location of the proposed

    amateur station (Please give

    House No., Street No., Road No.)

6. If your are exempted from :

    appearing in any part of the

    examination, give details of your

    qualifications.

    If you wish to appear for the :

    qualifying examination give

    the preferred centre and date

    of examination.

a) Centre :

b) Date / Month :

    Do you hold any other Licence

    earlier, if so give details.

    Licence No Callsign, if any

DECLARATION

I hereby solemnly 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 herein before is found false at a later date, the licence, 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 authorised 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 telegraph (amateur service) rules, 1978 and undertake to abide by them and observe the conditions of the licence. The licenced station shall not be made accessible to any authorised person at any time.

 

SIGNATURE OF WITNESS :                                                                                                      SIGNATURE OF APPLICANT

 

NAME (IN BLOCK LETTERS):                                                                                                   NAME (IN BLOCK LETTERS):

ADDRESS :

DATE:

 

DATE:

PLACE: