Annex D: Application Form for Paper Submission - Islands on the Air
Annex D: Application Form for Paper Submission - Islands on the Air
Annex D: Application Form for Paper Submission - Islands on the Air
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ANNEX D – APPLICATION FORM FOR PAPER SUBMISSION (PART 1)<br />
DIRECTIONS: Use this <str<strong>on</strong>g>for</str<strong>on</strong>g>m <str<strong>on</strong>g>for</str<strong>on</strong>g> all award applicati<strong>on</strong>s and score updates if you are not applying <strong>on</strong>-line. Please type or print<br />
clearly, and tick boxes where appropriate. Prepare your list in <strong>the</strong> <str<strong>on</strong>g>for</str<strong>on</strong>g>m specified in Part 2.<br />
CALL-SIGN .............................………………….. PREVIOUS CALL-SIGNS .....................................……………………..….………...<br />
(include <strong>on</strong>ly calls issued to you <str<strong>on</strong>g>for</str<strong>on</strong>g> pers<strong>on</strong>al use in your own DXCC entity)<br />
NAME …….……......……….....................................................................................................…………………….….……………………<br />
(First)<br />
(Last) (Spanish Apellido, Italian Cognome)<br />
NAME ..……....................................................................………………………….……………….... (as you want it to appear <strong>on</strong> awards)<br />
ADDRESS ...............………………...……………..………………………………………………………... (house name / number and street)<br />
...........................…….......………………………….…………………………………………………..………….. (village / town and / or city)<br />
..................................………………… (county / state) …...……...….………(zip) .............…….…………….…..………. (country if not UK)<br />
Please tick this box if this is a new address<br />
TELEPHONE (HOME) ............................…...………… (WORK) …………………………………..<br />
E-MAIL …………….....………...………….…………......……...……<br />
FAX ...............…..……………<br />
NUMBER OF CARDS ENCLOSED ..…………....….<br />
NUMBER OF CREDITS CLAIMED ....………....<br />
______________________________________________________________________________________________________________________<br />
FIRST APPLICATION Applying On-line On <str<strong>on</strong>g>Paper</str<strong>on</strong>g> Fees Fees<br />
Checking Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> processing up to 120 credits (includes <strong>the</strong> cost of <strong>the</strong> 100 certificate)<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> additi<strong>on</strong>al credits (rate <str<strong>on</strong>g>for</str<strong>on</strong>g> 121 to 320 credits)<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> additi<strong>on</strong>al credits (rate <str<strong>on</strong>g>for</str<strong>on</strong>g> 321 credits upwards)<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> claimed credits from <strong>the</strong> IOTA C<strong>on</strong>test Database<br />
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with applicati<strong>on</strong>)<br />
TOTAL (after discount)<br />
Band / Mode Endorsement Required .........…………<br />
UPDATE Applying On-line On <str<strong>on</strong>g>Paper</str<strong>on</strong>g><br />
Checking Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> processing up to 300 credits — see <str<strong>on</strong>g>Annex</str<strong>on</strong>g> B <str<strong>on</strong>g>for</str<strong>on</strong>g> Minimum Charge<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> additi<strong>on</strong>al credits (over 300 credits)<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> claimed credits from <strong>the</strong> IOTA C<strong>on</strong>test Database<br />
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with applicati<strong>on</strong>)<br />
TOTAL (after discount)<br />
Band / Mode Endorsement Required .........………… (your record must already show this as <strong>the</strong> chosen opti<strong>on</strong>)<br />
……….<br />
.…..…..<br />
.…..…..<br />
……….<br />
…........<br />
.…..…..<br />
……….<br />
APPLICATION FOR CERTIFICATES ............................................................………………….........<br />
Indicate certificates claimed (100, 200, 300, 400, 500, 600, 700, 800, 900, 1000, AF, AI, AN, AS, BI, EU, NA, OC, SA, WI, WW)<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> certificate(s) sent by post<br />
………<br />
Fee <str<strong>on</strong>g>for</str<strong>on</strong>g> certificate(s) sent electr<strong>on</strong>ically<br />
………<br />
*** Less 15% of total fee if an RSGB member *** (RadCom address label must be enclosed with applicati<strong>on</strong>)<br />
TOTAL (after discount)<br />
RECORD SHEET REQUESTED (<strong>on</strong>ly available to applicants submitting <strong>on</strong> paper)<br />
APPLICATION FOR 750 ISLANDS PLAQUE OF EXCELLENCE — see <str<strong>on</strong>g>Annex</str<strong>on</strong>g> B <str<strong>on</strong>g>for</str<strong>on</strong>g> price<br />
APPLICATION FOR 1000 ISLANDS TROPHY — see <str<strong>on</strong>g>Annex</str<strong>on</strong>g> B <str<strong>on</strong>g>for</str<strong>on</strong>g> price<br />
(includes <strong>the</strong> cost of <strong>the</strong> 1000 certificate)<br />
APPLICATION FOR PLAQUE & TROPHY SHIELDS (indicate what you are claiming)<br />
…..........<br />
…..........<br />
...….......<br />
...….......<br />
…..........<br />
…..…....<br />
……......<br />
POSTAGE FOR RETURN OF CARDS COST …..........<br />
Internati<strong>on</strong>al Signed For <strong>Air</strong> Mail Priority Mail (USA <strong>on</strong>ly)<br />
Recorded Signed For Small Packet <strong>Air</strong>mail Certified Mail (USA <strong>on</strong>ly)<br />
(recommended <str<strong>on</strong>g>for</str<strong>on</strong>g> UK) Ordinary Mail First Class Mail (USA <strong>on</strong>ly) TOTAL FEE ENCLOSED …...……<br />
APPLICANTS IN OTHER CURRENCIES: Please calculate <strong>the</strong> amount in UK pounds and apply <strong>the</strong> exchange rate provided <strong>on</strong> your<br />
Checkpoint’s page <strong>on</strong> <strong>the</strong> RSGB IOTA web-site at http://www.rsgbiota.org. O<strong>the</strong>rwise, ask your Checkpoint. This will give you <strong>the</strong><br />
precise fee owed.<br />
DECLARATION: I DECLARE THAT all <strong>the</strong> c<strong>on</strong>tacts <str<strong>on</strong>g>for</str<strong>on</strong>g> which QSL cards are submitted were made by me pers<strong>on</strong>ally from <strong>the</strong> same DXCC entity<br />
and in accordance with <strong>the</strong> terms of my radio transmitting licence, and that n<strong>on</strong>e of <strong>the</strong> QSL cards has been amended in any way since receipt. I<br />
accept that a breach of <strong>the</strong>se or any IOTA rules or bad behaviour <strong>on</strong> or off <strong>the</strong> air that is judged by <strong>the</strong> IOTA Committee to bring IOTA into disrepute<br />
may result in disqualificati<strong>on</strong> from <strong>the</strong> award programme. I fur<strong>the</strong>r accept that <strong>the</strong> decisi<strong>on</strong> of <strong>the</strong> IOTA Committee shall be final in all cases of<br />
dispute. I agree to <strong>the</strong> data from this applicati<strong>on</strong> being entered into a computer <str<strong>on</strong>g>for</str<strong>on</strong>g> <strong>the</strong> sole purpose of <strong>the</strong> management of this award programme.<br />
(Club Category Applicants, please amend <strong>the</strong> first two lines appropriately)<br />
Signature .....................................……...………… Call-sign ...............……....………….........Date<br />
.…….....……...................…….
ANNEX D – APPLICATION FORM FOR PAPER SUBMISSION (PART 2)<br />
Call-sign ...................…....<br />
DIRECTIONS: We firmly hope you will apply <strong>on</strong>-line <strong>on</strong> Internet. If you do not or cannot do so, please use this <str<strong>on</strong>g>for</str<strong>on</strong>g>m, listing cards<br />
numerically by IOTA reference number (IOTA Ref), by c<strong>on</strong>tinent in <strong>the</strong> following order: AF—AN—AS—EU—NA—OC—SA. Give <strong>the</strong><br />
call-sign, island name and o<strong>the</strong>r details as recorded <strong>on</strong> <strong>the</strong> card. See Secti<strong>on</strong> C.5 <str<strong>on</strong>g>for</str<strong>on</strong>g> examples and guidance.<br />
Date Time Call-sign IOTA Ref Island Name Frequency Mode<br />
(DDMMYY) (UTC) (as given) (by c<strong>on</strong>tinent) (from QSL) Band (MHz) (CW/PH/DATA)<br />
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