<p> SOCIALIST REPUBLIC OF VIETNAM Independence-Freedom-Happiness ------Day Month </p><p>APPLICATION FOR LICENSE OF USING FREQUENCY AND AMATEUR RADIO TRANSMITTER</p><p>To: The Department General of Post and Telecommunications Name of individual or name of the organization representative requesting the license:</p><p>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 :</p><p>Date of issue : (day , month , year) </p><p>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: </p><p>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</p><p>・Band width : Please See above for the Band width.</p><p>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</p><p>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.</p><p>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.</p><p>Certified by the organization or by the local government Signature of the applicant </p><p> day month (Signature and Seal) </p><p>~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~</p>