Ministere Des Postes Et Des Telecommunications
Service National des Radiocommunications
Centre de Gestion des Radiocommunications
(Memo of reference for the use of a radio station in France)

A.
Name:
Given names:
Date and place of birth:
Present residence:

Nationality:
Telephone numbers

B.
Earlier residences for the past 10 years
From to:
From to:
From to:

Professions excercised for the past 10 years
From to:
From to:
From to:

C.
Station used: (1)
Place of use in France:

Using period:

(1) Specify: Amateur or telecommande (radio control)

I, the undersigned, certify to the accuracy of the references above

A ____________________, le______________________

Signature: