Award Application updated 01 April 2017
From: ______________________________________________
____________________________________________________
____________________________________________________
Email address:________________________________________
To: METRO DX CLUB
3810 N. Chamlin Drive
Morris, IL 60450
USA
Application for award: (INDICATE below with an "X" THE AWARD YOU WANT) (Click on award name to see a sample and for rules)
W.U.S.T. AWARD (US$8.00)_______ Original award US$8.00 between 13 and 15 entities. Endorsement to original award US$3.00 for #14 or #15. A SPECIAL HISTORIC award is available for those contacting the ORIGINAL SIXTEEN DXCC territories including Kingman Reef (KH5K).
METRO GOLD CERTIFICATE (US$5.00)_______
Awards fee: US$____________________ enclosed. A PayPal payment to w9ty@arrl.net is also accepted.
The information and/or QSL cards required for this award have been checked and are certified to be correct by the following radio amateurs:
_______________________________________________ _______________
Signature Callsign
_______________________________________________ _______________
Signature Callsign
I declare that all the necessary credits for this award have been obtained in accordance with the rules of the award, as well as the rules and regulations for radio amateurs in my country. Please accept this information and send the award to my QTH as listed above.
Applicant's Signature: ________________________________________________ Callsign:___________________
Date: ________________
I learned about this award from (please let us know!): __________________________________________________________________________________________
NOTICE: For the W.U.S.T. Award, if you are at the TOP OF THE ARRL DXCC HONOR ROLL as printed in the most recent QST (normally the August edition), you automatically qualify for the award without having to send copies of QSL cards. You must write "TOP OF THE ARRL DXCC HONOR ROLL IN QST AUGUST 2010" (or the most current year of QST) on this Award Application in the "QSO Data" section below. This applies ONLY to those who are at the VERY TOP of the ARRL DXCC Honor Roll.
Photocopies of QSL cards are OK.
For an LoTW confirmation, it must be verified by two amateurs as does a QSL card, or a copy of the screenshot of the LoTW QSL confirmation detail may be substituted.
QSO data:
Territory QSO Indicate with "X" the
No. Prefix/Name Callsign Date Time Band Mode Type of confirmation
1. KG4 Guantanamo Bay __________ _________ _________ ____ ____ ____QSL Card___ LoTW____
2. KHØ Mariana Islands __________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
3. KH1 Baker & Howland __________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
4. KH2 Guam ___________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
5. KH3 Johnston Island __________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
6. KH4 Midway Island ___________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
7. KH5 Palmyra & Jarvis __________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
8. KH5K Kingman Reef ___________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____ (DELETED 01APR2016)
9. KH7K Kure Island ___________ _________ _________ ____ ____ ____QSL Card___ LoTW_____
10. KH8 American Samoa __________ _________ _________ ____ ____ ____QSL Card__ LoTW_____
11. KH8S Swains Island ___________ _________ _________ ____ ____ ____QSL Card __ LoTW_____
12. KH9 Wake Island ___________ _________ _________ ____ ____ ____QSL Card__ LoTW_____
13. KP1 Navassa Island ___________ _________ _________ ____ ____ ____QSL Card __ LoTW_____
14. KP2 US Virgin Islands __________ _________ _________ ____ ____ ____QSL Card ___ LoTW_____
15. KP4 Puerto Rico ___________ _________ _________ ____ ____ ___QSL Card___ LoTW_____
16. KP5 Desecheo Island __________ _________ _________ ____ ____ ___QSL Card___ LoTW_____
For further information, send an email to: awards@metrodxclub.com