DXCC AWARD APPLICATION Required with Each New Submission and Endorsements) Please print clearly. Please complete all sections. I am applying for the following DXCC awards (check appropriate boxes) REQUIRED: FILL OUT CHART BELOW ______________________________________________________________ |M |P |C |R |S |1 |8 |4 |3 |2 |1 |1 |1 |1 |6 |2 |5 | |I |H |W |T |A |6 |0 |0 |0 |0 |7 |5 |2 |0 |M |M |B | |X |O | |T |T |0 |M |M |M |M |M |M |M |M | | |D | | |N | |Y | |M | | | | | | | | | | |X | | |E | | | | | | | | | | | | | | | | ___________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| New Award | | | | | | | | | | | | | | | | | | __________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Endorse | | | | | | | | | | | | | | | | | | ___________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| 5Band End | | | | | | | | | | | | | | | | | | ___________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| You must mark those qsos on your cards for which you wish credit ___ I have submitted an application via Logbook of the World # of QSL cards enclosed__________ # of total QSO's ___________ 5BDXCC Award Number _____________ 5BDXCC Award Date __________ Call Sign __________________________ Ex Calls __________________ Name ______________________________________________________________ Last (Spanish Apellido), First Mailing Addresss _________________________________________________ _________________________________________________________________ __________________________________________________________________ (City, State, Zip. Country) The above address is where your paperwork, cards, and certificate will be shipped _____ Check here if new address Email Address: ____________________________________________________ Telephone # ________________________________________________________ Name on Certificate ________________________________________________ Print exactly as you want it to appear on certificate Fees: Application fee for first-ever DXCC (includes one certificate and lapel pin, up to 120 QSOs): ARRL members $12, foreign non- ARRL members $22. Application fee for endorsements and additional new awards (per calendar year) ARRL members 1st submission of the year - $12 (up to 120 QSOs) ARRL members, additional submissions - $22 (up to 120 QSOs) Non-ARRL members 1st submission of the year - $22 (up to 120 QSOs) Non-ARRL members additional submissions - $32 (up to 120 QSOs) * Applicants in the US and possessions must hold current ARRL membership Additional Fees Certificate fee (new or replacement) - $12 plus postage A $0.15 fee applies for each QSO in excess of 120 QSO limit Applications processed "while-you-wait" at ARRL HQ - $9 fee (up to 120 QSOs) Applications presented at conventions attended by DXCC staff - $7 (up to 120 QSOs ) Complete DXCC fees are shown in Rule 15 of the Basic DXCC Rules. The use of a current DXCC application form is required. Do not use this form for plaque or pin orders. Return postage is required for the return of cards and all written requests. DXCC accepts most credit cards. If you are not sure of the correct charges, you may use a credit card. This will allow us to charge the exact amount. You must clear previous balances (per your last credit slip) with this submission in order to avoid delays. DXCC cannot bill you. Please provide the following information: Award Fees: ________________________ Estimated Postage: __________________ Total amount sent: __________________ Diamond Club Member Status: ____ Gold ____ Platinum Method of Payment: ___ U.S. Currency ___ Check or Money Order ___ Credit Card # ____________________________________________ Credit Card Exp Date: __________________ Return My QSL Cards Via: * ___Registered Mail (Recommended) ___First Class Mail ___Certified Mail (US Only) ___Airmail ___Fedex ___Other (Please Specify) __________________ * If left blank, we will ship via Registered Mail at your expense "I affirm that I have observed all DXCC rules as well as all governmental regulations established for Amateur Radio in my country. I understand that ARRL is not responsible for cards handled by DXCC Card Checkers and will not honor any claims. I agree to be bound by the decisions of the ARRL Awards Committee and that all decisions of the ARRL Awards Committee are final." _____________________________________________________________________ Signature (REQUIRED) Callsign Date ARRL Membership Expiration Date Send application forms, QSL cards, fees, and return postage to: DXCC Desk, ARRL HQ, 225 Main Street, Newington, CT 06111, U.S.A. For questions or clarifications, please write to the DXCC Desk at the above address, or via e-mail to dxcc@arrl.org To confirm the receipt of your application, go to this link: www.arrl.org/awards/dxcc/appstatus.html. The DXCC Desk can also be contacted as follows: Telephone: 860-594-0234, Fax: 860-594-0346 (24 hour direct line to ARRL HQ). For complete program information, please visit the DXCC web site at: www.arrl.org/awards/dxcc For ARRL DXCC Card Checker Use Only I affirm that I have personally inspected the confirmations and verify this application is true and correct. _______________________________________________________________________ Signature Callsign Date DXCC Card Checkers must forward the application and fees to HQ within 2 working days. FIELD CHECKED APPLICATIONS MAY BE SUBMITTED ONLY BY CARD CHECKERS. DXCC Record Sheet Your Callsign: ____________________________ Page ______ of _______ Note: Cards may be submitted directly to ARRL or checked by a DXCC Card Checker. If cards are sent direct to ARRL, it is not necessary to fill out this form. This form must be completed if a Card Checker checks the application. In either case, the cards or listed credits must be sorted first by band then by mode. If you fill out the form, supply all information as requested. Be sure to use the Entity name, not just the prefix. Cards indicating multiple contacts must be placed together. If cards with multiple credits are submitted direct to ARRL, a notation must be made on each card indicating which credits are to be entered. If no indication is made on a card, all credits will be entered into your record. _________________________________________________________________________ | QSO Date | | | Callsign | DD/MM/YY | Band | Mode | Entity Name _________________|__________________|________|_________|__________________ 1_______________ | _____ /____/_____| ______ | _______ | _________________ 2_______________ | _____/____/_____ | ______ | _______ | _________________ 3_______________ | _____/____/_____ | ______ | _______ | __________________ 4_______________ | _____/____/_____ | ______ | _______ | __________________ 5_______________ | _____/____/_____ | ______ | _______ |___________________ 6_______________ | _____/____/_____ | ______ | _______ | __________________ 7_______________ | _____/____/_____ | ______ | _______ | __________________ 8_______________ | _____/____/_____ | ______ | _______ | __________________ 9_______________ | _____/____/_____ | ______ | _______ | __________________ 10______________ | _____/____/_____ | ______ | _______ | __________________ 11______________ | _____/____/_____ | ______ | _______ | __________________ 12______________ | _____/____/_____ | ______ | _______ | __________________ 13______________ | _____/____/_____ | ______ | _______ | __________________ 14______________ | _____/____/_____ | ______ | _______ | __________________ 15______________ | _____/____/_____ | ______ | _______ | __________________ 16______________ | _____/____/_____ | ______ | _______ | __________________ 17______________ | _____/_____/____ | ______ | _______ | __________________ 18______________ | _____/____/_____ | ______ | _______ | __________________ 19______________ | _____/ ____/____ | ______ | _______ | __________________ 20______________ | _____/ ____/ ____| _____ | _______ | __________________ 21______________ | _____/_____/____ | ______ | _______ | __________________ 22______________ | _____/____/_____ | ______ | _______ | __________________ 23______________ | _____/ ____/____ | ______ | _______ | __________________ 24______________ | _____/ ____/ ____| _____ | _______ | __________________ 25______________ | _____/ ____/ ____| _____ | _______ | __________________ January 2007