SOCIALIST REPUBLIC OF VIETNAM Independence-Freedom-Happiness ------Day Month

APPLICATION FOR LICENSE OF USING FREQUENCY AND AMATEUR RADIO TRANSMITTER

To: The Department General of Post and Telecommunications Name of individual or name of the organization representative requesting the license:

Male/Female: Date of Birth (Day, Month, Year): Native town : Resident address : Educational level : Foreign language level : Profession : Position rank : Office address: Having amateur radio operator certificate issued by :

Date of issue : (day , month , year)

Requests the license to use frequency and the amateur radio transmitter with the following parameters to carry out the amateur radio communications. 1/ Duration of using : Temporarily from to ○Long term 2/ Application objective : ○New license Adding or changing the license No Issued on 3/ Location of the station:

4/ Type of Service : ○Fixed ○Mobile 5/ Type of Station : ○Fixed ○Mobile 6/ Characteristics of the radio transmitter or the radio transceiver: ・Type of Transmitter : ・Serial No. : . ・Manufacturer : ・Transmit power : ・Feeder loss : ・Modulation modes : Please See next page for the Modulation modes. ・Frequency band : Please See below for the Frequency bands. ・ HF Bands: Power 200W ： 3.803 MHz SSB 7.077 MHz SSB 14.000 MHz ～ 14.350 MHz SSB,CW,PSK,FSK,SSTV, RTTY 18.068MHz ～ 18.168 MHz SSB,CW,PSK,FSK,SSTV, RTTY 21.000 MHz ～ 21.450 MHz SSB,CW,PSK,FSK,SSTV, RTTY 24.890 MHz ～ 24.990 MHz SSB,CW,PSK,FSK,SSTV, RTTY, 28.000 MHz ～ 29.700 MHz SSB,FM,AM,CW,PSK,FSK,SSTV, RTTY ・ VHF Bands : Power 50W ： 50.000 MHz ～ 54.000 MHz SSB,FM,AM,CW,PSK,FSK,SSTV, RTTY 144.000 MHz ～ 145.990 MHz SSB,FM,AM,CW,PSK,FSK,SSTV, RTTY

・Band width : Please See above for the Band width.

7/ Transmit antenna ・Name : Vertical Antenna , Yagi-Uda Antenna ・Type : ●Vertical ●Horizontal ・Antenna gain: Vertical: 0dB Yagi-Uda: Gain dB maximum ・Polarization: Vertical: 360° Yagi-Uda: Rotatable ・Height of antenna from the earth surface: m ・Topological altitude (from the sea level) : ・Zenith angle of the main lobe: ° ～ ° ・Coordination of the antenna: Longitude ° ’ North Latitude ° ’ East

8/ Communication: ・Proposed call sign : ( ) ・Proposed transmit Frequency: Please see above for the transmit Frequency. ・Proposed modulation mode : Please see above for the modulation mode.

I assure that all my declarations are correct and I shall carry out seriously all the provisions and regulation of the Government on the amateur radio communication.

Certified by the organization or by the local government Signature of the applicant

day month (Signature and Seal)

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