APPLICATION FOR

10-10 PREFIX AWARD

PLEASE PRINT OR TYPE ALL INFORMATION

Name:_______________________________________________________________

Address:________________________________________________________________________

City:___________________________ State Or Country: ____________________Zip:________

Call:_______________ 10-10 Number:______________)10-10 Membership Expires:_________

I am applying for the following:

BASIC CERTIFICATE _____( First 100 Prefixes)

UPGRADE For ____________ Prefixes

DECLARATION:

By signing this application, I hereby certify that I have personally made contact with the

Stations listed and the station listed gave me his 10-10 number during the contact. My logs

Will be made available to the 10 – 10 Prefix Manager if so requested.

I have enclosed a copy of my Membership Card, or address label from the latest copy of

The 10-10 International News , showing my status as a paid up member of Ten-Ten.

Signature: ______________________________ Dated: ___________________________

LIST 100 CONTACTS ON REVERSE SIDE

OR

ATTACH COMPUTER PRINT-OUT LISTING THE SAME INFORMATION

SEND TO: 10-10 WPX AWARD MANAGER

AL LONGO NN1J

PO Box 94

Springfield , Maine 04487