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Application from an Individual for a licence to Establish, Maintain and Work an Amateur Wireless Telegraph Station in India :- (see rule 6 & 8 )
1. Name :
2. Father's name & address :
3. Address (present) :
4. Address (permanent) :
5. Date of birth -- Place of birth -- Nationality -- Occupation --
6. (a) Category of licence applied for ----- (b) Exact location of the Station -----
7. Do you hold Radio Telegraph Operator's Certificate? If yes, give particulars : (a) Name of the Certificate ----- (b) No. ----- (c) Date of issue -----
8. Particulars of Amateur Station Operator's Examination : (a) Name ---- (b) center ---- (c) month of Examination ----
9. Particulars of apparatus used : (a) Apparatus ----- (b) Manufacturer's Name ----- (c) Type No.---- (d) Frequency Range ---- (e) R.F.Power Output ----
10. If appeared in any of the Amateur Station Operator's Examination :- Yes / No
If yes , indicate the date of Examination :--------
DECLARATION
I hereby Solemnly 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 of any information given by me herein before is found false at a later date , the License , if granted , will be cancelled.
I further solenly give an undertaking that I will not either directly or indirectly divulge to any person, except when lawfully authorised or directed to dos so, the purport of any message which iI 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 the 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 licence.The licenced station shall not be made accessible to any unauthorised person at any time .
| Signature of the witness: Name : (in block letters) Address : Date : |
Signature of the Applicant : Name : (in block letters) Address : Date : |
Note : 1. An attested copy of the Birth Certificate or school leaving certificate must be accompanied along with the application.
2. Enclose the certificate in support of Nationality in the prescribed proforma , indicated in Appendix III , from one of the Officers listed therein.
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