FSD-187: Application for Station Appointment

All "starred" fields ( * ) on this form must be completed before submission.

Name *

Call Sign *

Address *

City *

State *

Postal Code *

E-mail *

Phone (Day)

Phone (Evening)

Phone (Cell)

I hearby apply for the following appointment(s)

(**For OES only) Recommending EC/DEC (Name/Call Sign)

My qualifications are:

I agree to maintain current League membership, and report my station activity on a regular basis.

ARRL