Name: ________________________________________________________________________
(Surname first in Block Letters)
Nationality: _________________________________________ Occupation: __________________
Birthplace: _________________________________________ Date of Birth: ________________
Licence Number: ____________________________________ Expiration Date: _______________
Call Sign: __________________________________________ Country of Issue: ______________
Proposed Operation on: ________________________________ (Antigua or Barbuda)
From (If applicable): _________________________________ To: __________________ (Dates)
Frequency Band(s): ___________________________________ Type(s) of Emission: ___________
Fixed/Portable/Mobile: _________________________________ XMTR. Power Input: __________
Location if Fixed: _____________________________________ AMP. Dc Input Power: ________
Description of Equipment: _________________________________________________________
_______________________________________________________________________________
Mailing address in Antigua and Barbuda: ______________________________________________
_______________________________________________________________________________
Mailing address in your Country: ____________________________________________________
_______________________________________________________________________________
I the undersigned request a Licence/Permit to operate an Amateur Raduio Station in Antigua and Barbuda and agree that if a Licence/Permit is granted, my operation will be according with:
1. The Rules of the ITU Radio Regulations governing Amateur Radio operation.
2. The terms and conditions of the Amateur Radio Licence issued to me by the Government of Antigua and Barbuda.
3. The terms and conditions of the Amateur Radio Licence issued to me by my Government (If applicable).
4. Any further conditions to the Licence/Permit that may be laid down by the Telecommunications Officer.
I further understand that any Licence/Permit issued to me may be summarily Modified, Suspended or Cancelled without advance notice.
I certify that all the information submitted herein or herewith are true and correct and complete to the best of my knowledge.
Date: ___________________________ 19 ____, _________________________________ (Signature)