annex a - iota members application form (part 1) - Islands on the Air

ANNEX C – IOTA MEMBERS APPLICATION FORM (PART 1)
DIRECTIONS: Use this <strong>form</strong> for all award <strong>application</strong>s and score updates if you are not applying on-line. Please type or print
clearly, and tick boxes where appropriate. Prepare your list in the <strong>form</strong> specified in Part 2.
CALL-SIGN .............................………………….. PREVIOUS CALL-SIGNS .....................................……………………..….………...
(include only calls issued to you for personal use in your own DXCC entity)
NAME …….……......……….....................................................................................................…………………….….……………………
(First)
(Last) (Spanish Apellido, Italian Cognome)
NAME ..……....................................................................………………………….……………….... (as you want it to appear on awards)
ADDRESS ...............………………...……………..………………………………………………………... (house name / number and street)
...........................…….......………………………….…………………………………………………..………….. (village / town and / or city)
..................................………………… (county / state) …...……...….………(zip) .............…….…………….…..………. (country if not UK)
Please tick this box if this is a new address
TELEPHONE (HOME) ............................…...………… (WORK) …………………………………..
E-MAIL …………….....………...………….…………......……...……
FAX ...............…..……………
NUMBER OF CARDS ENCLOSED ..…………....….
NUMBER OF CREDITS CLAIMED ....………....
______________________________________________________________________________________________________________________
FIRST APPLICATION Applying On-line On Paper Fees Fees
Checking Fee for processing up to 120 credits (includes the cost of the 100 certificate)
Fee for additional credits (rate for 121 to 320 credits)
Fee for additional credits (rate for 321 credits upwards)
Fee for claimed credits from the IOTA Contest Database
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with <strong>application</strong>)
TOTAL (after discount)
Band / Mode Endorsement Required .........…………
UPDATE Applying On-line On Paper
Checking Fee for processing up to 300 credits — see Annex B for Minimum Charge
Fee for additional credits (over 300 credits)
Fee for claimed credits from the IOTA Contest Database
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with <strong>application</strong>)
TOTAL (after discount)
Band / Mode Endorsement Required .........………… (your record must already show this as the chosen option)
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APPLICATION FOR CERTIFICATES ............................................................………………….........
Indicate certificates claimed (100, 200, 300, 400, 500, 600, 700, 800, 900, 1000, AF, AI, AN, AS, BI, EU, NA, OC, SA, WI, WW)
Fee for certificate(s) sent by post
………
Fee for certificate(s) sent electronically
………
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with <strong>application</strong>)
TOTAL (after discount)
RECORD SHEET REQUESTED (only available to applicants submitting on paper)
APPLICATION FOR 750 ISLANDS PLAQUE OF EXCELLENCE — see Annex B for price
APPLICATION FOR 1000 ISLANDS TROPHY — see Annex B for price
(includes the cost of the 1000 certificate)
APPLICATION FOR PLAQUE & TROPHY SHIELDS (indicate what you are claiming)
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POSTAGE FOR RETURN OF CARDS COST …..........
International Signed For Air Mail Priority Mail (USA only)
Recorded Signed For Small Packet Airmail Certified Mail (USA only)
(recommended for UK) Ordinary Mail First Class Mail (USA only) TOTAL FEE ENCLOSED …...……
APPLICANTS IN OTHER CURRENCIES: Please calculate the amount in UK pounds and apply the exchange rate provided on your
Checkpoint’s page on the RSGB IOTA web-site at http://www.rsgb<strong>iota</strong>.org. Otherwise, ask your Checkpoint. This will give you the
precise fee owed.
DECLARATION: I DECLARE THAT all the contacts for which QSL cards are submitted were made by me personally from the same DXCC entity
and in accordance with the terms of my radio transmitting licence, and that none of the QSL cards has been amended in any way since receipt. I
accept that a breach of these or any IOTA rules or bad behaviour on or off the air that is judged by the IOTA Committee to bring IOTA into disrepute
may result in disqualification from the award programme. I further accept that the decision of the IOTA Committee shall be final in all cases of
dispute. I agree to the data from this <strong>application</strong> being entered into a computer for the sole purpose of the management of this award programme.
(Club Category Applicants, please amend the first two lines appropriately)
Signature .....................................……...………… Call-sign ...............……....………….........Date
.…….....……...................…….

IOTA MEMBERS APPLICATION FORM (PART 2)
Call-sign ...................…....
DIRECTIONS: We firmly hope you will apply on-line on Internet. If you do not or cannot do so, please use this <strong>form</strong>, listing cards
numerically by IOTA reference number (IOTA Ref), by continent in the following order: AF—AN—AS—EU—NA—OC—SA. Give the
call-sign, island name and other details as recorded on the card. See Section C.5 for examples and guidance.
Date Time Call-sign IOTA Ref Island Name Frequency Mode
(DDMMYY) (UTC) (as given) (by continent) (from QSL) Band (MHz) (CW/PH/DATA)
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