The 73 International Universal Permit Application
The following-named radio amateur respectfully requests the permission of the government of __________________ to operate amateur radio equipment in the country. If permission is granted, I, the undersigned, agree to operate in accordance with the rules, regulations and conditions established by the permission-issuing government, by the terms and conditions of the bilateral agreement (if any) between the permit-issuing country and my country, rules of the (ITU) Geneva Radio Regulations governing radio operations, and the rules and regulations of my country. Furthermore, I certify that the following information is true and accurate.
Full signature: _______________________________________ Date: ______________________
PERSONAL INFORMATION
1. Family Name(s) _________________________ 2. Given Name(s) _______________________
3. Country of Residence _____________________4. Citizen? ___ by Birth? ___ Naturalized? ___
5. Nationality _____________________________ 6. Place/Date of Birth ____________________
7. Home Address _______________________________________________________________
8. Personal description (if not included on passport or other official ID attached here: Color hair, eyes, weight,height):
_____________________________________________________________________________
9. Attach photocopies of passport pages showing name, number, and other selected data. (If passport not required for entry, attach photocopies of Birth Certificate and official ID showing picture: such as driving license.)
10. Occupation (profession and place of employment) _____________________________________
AMATEUR RADIO INFORMATION
11. Callsign _________________ 12. Operation license number (if any) and class _______________
13. Expiration date (if none given attach notorized certificate that license is valid) ______________
14. Attach photocopy of license (if Morse speed not shown, indicate here) ___________________
INFORMATION ABOUT PLANNED VISIT
15. Arrival/permit to be effective date _____________ 16. Departure/permit end date ____________
17. Address(es) in permit Country ___________________________________________________
18. Location(s) of operation(s) ______________________________________________________
19. Description of equipment (brands, models, XMTR, RCVR, XCVR, power amps, antenna(s), power, bands, and types of emissions
_____________________________________________________________________________
20. Point and manner of entry of operator and equipment into Country _________________________
50. SPECIAL INFORMATION FOR THIS PERMIT-ISSUING COUNTRY (if any)
51. __________________________________________________________________________
52. __________________________________________________________________________
53. __________________________________________________________________________
54. __________________________________________________________________________