Award Application



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