Nr_________ LQ__________ Activity Group of Belarus Membership Application Name Call: Date of birth Licensed HAM since Member of: 10X#, QCWA#, HSC#, DIG#, AGCW#, UDXC# QTH: Mail address: E-mail* Phone* Fax* (* if available) I state that: - I have amateur radio license (personal call or SWL) . - I have 175 or more DXCC countries confirmed, or - I have 50 awards, or - I have 10 Contest-awards for 1..3 place (World, Continent, Country). - I shall annually inform AGB about my progress in DXCC, contesting and awards hunting - at the end of year - to count my AGB rating. Now I have: - "A" - Awards - "C" - Contest-awards - "D" - confirmed DXCC countries * Remark: The list of my awards, Contest awards and number of confirmed DXCC countries (total and by bands) is attached to this application. Date "____"_____________20____ Signature__________________ Date "____"_____________20____ AGB-President /EU1EU