DX Countries Award Application

Please print your Name: 							 Call: 					

Address: 									 Ten-Ten #: 				

City: 								 State or Country: 					

Postal Zip Code: 				 E-mail Address: 							

Basic or Endorsement applying for (Circle One)

35	45	55	65	75	
80	85	90	95	100	
105	110	115	120	125	
130	135	140	145	150	
155	160	165	170	175	
180	185	190	195	200	
205	210	215	220	225	
230	235	240	245	250	
255	260	265	270	275	
280	285	290	295	300	

I verify, by my signature, that I have made the enclosed contacts in accordance with the rules of the Ten-Ten International DX Countries Award Program.

Signature: 								 Date: 				

© Copyright 2008 - 2020    10-10 International.

Page 1

10-10 DX Countries Awards Claim Sheet Worksheet 

Call _________________________ 1010# _____________

Country #	Call Sign	Ten-Ten #	DX Country	Date	
1					
2					
3					
4					
5					
6					
7					
8					
9					
10					
11					
12					
13					
14					
15					
16					
17					
18					
19					
20					
21					
22					
23					
24					
25					

Send Application To:
Mike Davidson, N5MT
26274 Whispering Pines Ave
Denham Springs, LA 70726, USA
E-mail: N5MT@aol.com

© Copyright 2008 - 2020     10-10 International.

Page 2