From: NAME _____________________________
ADDRESS _____________________________
_____________________________
To: Metro DX Club
3810 N. Chamlin Drive
Morris, IL 60450
Application for: METRO GOLD CERTIFICATE
Awards fee enclosed: US$5.00
The information and/or QSLs 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: ____________________________ Date:___________
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