Application For 10-10 Counties Award

Date: ______________ Basic Award : #___________________ Up Grade to: ________#____________

Name: __________________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________________

Call: _________________ 10-10 #: ___________________ Expiration: ______________________

Ex-Calls (optional): ________________ E-Mail Address (optional): ______________________

(NOTE: Each Counties application must contain exactly 100 contacts. List each contact on a separate line and alphabetically by state and then county. QSL confirmation is NOT required.)

State County 10-10 # Call sign Name Contact Date

1____________|__________________|____________|____________|_______________|_____________

2____________|__________________|____________|____________|_______________|_____________

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18___________|__________________|____________|____________|_______________|_____________

19___________|__________________|____________|____________|_______________|_____________

20___________|__________________|____________|____________|_______________|_____________

Application For Counties Award (continued)

State County 10-10 # Call sign Name Contact Date

21___________|__________________|____________|____________|_______________|_____________

22___________|__________________|____________|____________|_______________|_____________

23___________|__________________|____________|____________|_______________|_____________

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47___________|__________________|____________|____________|_______________|_____________

48___________|__________________|____________|____________|_______________|_____________

49___________|__________________|____________|____________|_______________|_____________

Application For Counties Award (continued)

State County 10-10 # Call sign Name Contact Date

50___________|__________________|____________|____________|_______________|____________

51___________|__________________|____________|____________|_______________|____________

52___________|__________________|____________|____________|_______________|_____________

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66___________|__________________|____________|____________|_______________|_____________

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76___________|__________________|____________|____________|_______________|_____________

77___________|__________________|____________|____________|_______________|_____________

78___________|__________________|____________|____________|_______________|_____________

Application For Counties Award (continued)

State County 10-10 # Call sign Name Contact Date

79___________|__________________|____________|____________|_______________|____________

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100__________|__________________|____________|____________|_______________|____________

Just in Case

Spare_________|__________________|____________|____________|_______________|____________

Spare_________|__________________|____________|____________|_______________|____________

Have you included a copy of your Membership Card, $2.00 US & $3.00 DX for Basic, SASE US

& $1.00 DX for upgrades Thank you for your participation in the 10-10 Award Program

You made contacts for these results

Mail To: COUNTIES AWARD MANAGER, Brad Kimble KØDBK #55192, 3855 66th Street,

Iver Grove Hights, MN 55076-2222, e-mail k0dbk@comcast.net Effective - January 1, 2000