Demande De Licence
Pour L'utilisation Temporaire D'une Station D'amateur En France
(Request for use in France of a radio station)

1. Information about the petitioner
Name:
Given names:
Date and place of birth:
Nationality:
Present residence:

Telephone number:

Call sign:

2. Information about the station
Make:
Type:
Serial number:
Range covered:
Type of modulation:
Supply power:
Power dissipation:
Amplifier:

Aerial:

Place of use in France:

Period the station will be used:

Number of the motorcar on which I intend to use the station:

A__________________________, Le__________________________

Signature: