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 "____"_____________19____	Signature__________________

Date "____"_____________19____	AGB-President /EU1EU-OK8EU/