DXCC AWARD APPLICATION
	   (Required with Each New Submission and Endorsements)
           Please print clearly.  Please complete all sections


I am applying for the 		Call Sign _____________________				
following DXCC awards (check  									
appropriate boxes)   		Ex Calls  _________________________________						
REQUIRED:  FILL OUT CHART        
BELOW				Name ______________________________________					
__________________________  		Last (Spanish Apellido), First		
       |        |         |             
Award  |  New   |  	  |     Mailing Addresss __________________________       
 Type  | Award  | Endorse |           		     Number and Street
_______|________|_________|    	___________________________________________          
 Mixed |________|_________|  	___________________________________________		   			
 Phone |________|_________|             (City,State/Zip, Country)        
 CW    |________|_________|     This is where your paperwork, cards, and  
 RTTY  |________|_________|	certificate will be sent         
 SAT.  |________|_________|    
 160   |________|_________|    _____ Check here if new address
  80   |________|_________|   
  40   |________|_________|    Email Address:  _____________________________	
  20   |________|_________|       
  17   |________|_________|    Telephone # _________________________________ 
  15   |________|_________|   
  12   |________|_________|    Name on Cetificate __________________________
  10   |________|_________|                  Print exactly as you want it to
   6   |________|_________|                  appear on certificate  
   2   |________|_________|    
5BDXCC |________|160-17-12-				
		 6-2        
      Circle band(s) above	   | Please provide the following information:   
		                   |              
5BDXCC Award Number ____________   | Award Fees:        __________          
                    Needed for     | Estimated Postage: __________          
                    Endorsements   | Total Amount Sent: __________
5BDXCC Award Date ______________   |
				   | Method of Payment:	
# of QSL cards enclosed_________   | ____ U.S. Currency
# of total QSO's _______________   | ____ Check or Money Order	
  				   | 
				   | ____ Credit Card # ___________________
Fees: 				   |      Exp. Date _______________________  
			           | 
Initiation - $10 (First ever DXCC, | Return my QSL Cards Via:*
includes one certificate and DXCC  |
pin. Up to 120 QSOs).	 	   | ____ Registered Mail (Recommended) 
Application fee for endorsements   | ____ First Class Mail
and additional new awards (per	   | ____ Certified Mail (US Only)	
calendar year)			   | ____ Airmail
. ARRL members 1st submission of   | ____ United Parcel Service (US Only)
  the year - $10 (up to 120 QSOs)  | ____ Other (please specify) __________	
. ARRL members, additional         | 
  submissions - $20 each (up to    | "I affirm that I have observed all DXCC 
  100 QSOs)  			   | rules as well as all governmental 
· Non-ARRL members (non-US only*)  | regulations established for Amateur Radio 	
  1st submission of the year - $20 | in my country. I understand that ARRL is 
  (up to 120 QSOs)		   | not responsible for cards handled by 	
· Non-ARRL members (non-US only*)  | DXCC Card Checkers and will not honor any 	
  additional submissions - $30     | claims. I agree to be bound by the  
  each (up to 100 QSOs)        	   | decisions of the ARRL Awards Committee  
				   | and that all decisions of the ARRL Awards    
Additional Fees			   | Committee are final." 	
				   |	
. Certificate fee (new or	   | ________________________________________	
  replacement) - $10 (includes one | Signature (REQUIRED)            Callsign
  DXCC pin) 			   |	
· A $0.15 fee applies for each QSO |  
  in excess of the established     | ________________________________________
  limits     			   | Date     ARRL Membership Expiration Date
· All applications presented at    |
  ARRL HQ or conventions attended  |   
  by DXCC staff - $5 surcharge     |
  (limit 120 QSOs) 		   | Send application forms, QSL cards, fees,
   				   | and return postage to:  DXCC Desk, ARRL 		 	
· Complete DXCC fees are shown in  | HQ, 225 Main Street, Newington, CT 06111, 	  
  Rule 15 of the Basic DXCC Rules  | U.S.A.
				   | 
* NOTE: All applicants in the US   | 
  and possessions must hold        | For questions or clarifications, please  
  current ARRL membership	   | write to the DXCC Desk at the above	
				   | address or via email to dxcc@arrl.org
· The use of a current DXCC 	   | 	
  application form is required 	   | To confirm receipt for your application,  	
· Do not use this form for plaque  | go to this link:	
  or pin orders			   | www.arrl.org/awards/dxcc/appstatus.html 
· Return postage is required for   | The DXCC Desk can also be contacted as
  the return of cards and all      | follows:
  written information requests	   |  	
· DXCC accepts most credit cards.  | Telephone:  860-594-0234
  If you are not sure of the       | Fax:  860-594-0259 
  correct charges, you may use a   | 
  credit card. This will allow 	   | For complete program information, please 
  us to charge the exact amount.   | visit the DXCC web site at:
  You must clear previous 	   | www.arrl.org/awards/dxcc	
  balances (per your last          |  
  credit slip) with this           | 
  submission in order to avoid     | 
  delays.			   |	
· DXCC cannot bill you             |

			For ARRL DXCC Card Checker Use Only

I affirm that I have personally inspected the confirmations and verify that 
this application is true and correct.

______________________________________________________________________________
Signature                            Callsign                     Date

DXCC Card Checkers must forward the application and fees to HQ within 2
working days.  FIELD CHECKED APPLICATIONS MAY BE SUBMITTED ONLY BY CARD
CHECKERS.

MSD-505 (04/2001)