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Wireless Monitoring Stations

HAM RADIO EXAMINATION (ASOC EXAMINATION)


APPLICATION FORM FOR AN INDIVIDUAL FOR A LICENSE TO ESTABLISH, MAINTAIN AND WORK AN AMATEUR WIRELESS TELEGRAPH STATION IN INDIA

(See Rules 6 & 8)

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                      ____________________

your qualifications

(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):

Date: Date:

Place:

________________________________________________________________

(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.