Asoc Application Form 161p
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ANNEXURE II Application from an individual for a licence to Establish, Maintain and Work an Amateur Wireless Telegraph Station in India. (See rules 6 & 8)
1.Name:( In Capitals)
………………………………..……………………………………………………… (Last name) (First) (Middle)
2. Father's Name : and Address 3. Address (Present) :
4. Address (Permanent) : City/Town State Res. No. Mobile No. Personal Email
5. Date of Birth
(DD/MM/YYYY)
District PIN
Place of Birth
Nationality
Occupation
INDIAN (b) Exact location of the Station
6. (a) Category of licence applied for
(Including name of City, Dist, State & PIN)
7. Do you hold Radiotelegraph Operator's Certificate? If yes, give particulars: Name of the certificate
Cert. No.
8. Particulars of Amateur Station Operator's Examination:Name Centre
Date of Issue
Yes / No Validity
Month of Examination
9. Particulars of apparatus to be used: Manufacturer's Frequency Apparatus used` Name Type No. Range R.F. Power Output To Be Homebrewed or purchased after getting Licence Transmitter Receiver
Frequency Measuring Device
10. If appeared in any of the Amateur Station Operator's Examination. (If yes, indicate the date of the examination)
Yes / No
DECLARATION I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed there from. I also agree that in case any information given by me herein before is found false at a later date, the licence, if granted, will be cancelled. I further solemnly give an undertaking that I will not either directly or indirectly divulge to any person, except when lawfully authorised or directed to do so, the purport of any message which I may transmit or receive by means of any wireless apparatus operated by me or which may come to my knowledge in connection with the operation of said apparatus. I have carefully read and understood the rules contained in the Indian Wireless Telegraphs (Amateur Service) Rules, 1978 and undertake to abide by them and observe the conditions of the licence. The licensed station shall not be made accessible to any unauthorised person at any time. Signature of witness
Signature of applicant
Name (in block letters)
Name (in Block letters):
Address:
Date :
Date :
Place :
APPENDIX III NATIONALITY CERTIFICATE Certified that I have known Shri / Smt / Kum ____________________________________ son/daughter of Shri ______________________________
for the last _______ years and
that to the best of my knowledge and belief he/she bears a good moral character. He / She is of INDIAN nationality. He / She is not related to me. Address :
Signature:
Dated:
Designation : Office Seal (Should not be only in local language)
Note- This certificate should be from one of the officers listed below :1. Gazetted officers of Central or State Governments. 2. of Parliament or State Legislatures. 3. Sub-Divisional Magistrate/Officer. 4. Tahsildars or Naib/Deputy Tehsildars Authorised to exercise magisterial powers. 5. Principal / Head Master / Head Mistress of the recognized institutions (School / College) if applicant is a Bonafide student of that institution.
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 1. Name in full ( in block letters)
:
2. Date of birth
:
3. Place of birth
:
4. Age
:
5. Height
:
6. Colour of eyes
:
7. Complexion
:
8. Colour of hair
:
9. Identification marks
:
10. Full address (in block letters)
: Pin:
11. Occupation (Major work or profession for which you receive money) 12. Nationality 13. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
16. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 12. Name in full ( in block letters)
:
13. Date of birth
:
14. Place of birth
:
15. Age
:
16. Height
:
17. Colour of eyes
:
18. Complexion
:
19. Colour of hair
:
20. Identification marks
:
21. Full address (in block letters)
: Pin:
22. Occupation (Major work or profession for which you receive money) 12. Nationality 14. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
17. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 23. Name in full ( in block letters)
:
24. Date of birth
:
25. Place of birth
:
26. Age
:
27. Height
:
28. Colour of eyes
:
29. Complexion
:
30. Colour of hair
:
31. Identification marks
:
32. Full address (in block letters)
: Pin:
33. Occupation (Major work or profession for which you receive money) 12. Nationality 15. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
18. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 34. Name in full ( in block letters)
:
35. Date of birth
:
36. Place of birth
:
37. Age
:
38. Height
:
39. Colour of eyes
:
40. Complexion
:
41. Colour of hair
:
42. Identification marks
:
43. Full address (in block letters)
: Pin:
44. Occupation (Major work or profession for which you receive money) 12. Nationality 16. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
19. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Government of India Ministry of Communication & Information Technology Department of Telecommunication Wireless Monitoring Organisation IWMS, Perungudi, Chennai – 96 (Two copies of this page are to be submitted)
___________________________________
Date
____________________
To
____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Subject:- Result of Amateur Station Operators Certificate – Restricted Grade Exam held on ____________ at ____________________ Roll No: ______________ Sir/Madam, I am directed to inform you that:1) You have been declared successful in ______________________ Examination. The papers are being forwarded to the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT: 616, Sanchar bhavan, 20, Ashoka Road, New Delhi – 1100 001. As soon as the decision to grant the Amateur License is taken by the Ministry, you will be intimated by the Ministry accordingly. You are requested not to send any money or papers until unless it is asked for. 2) You have not qualified in the ______________________ Examination. 3) Communication regarding grant of license will be sent to you by the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT, New Delhi in due course. 4) You may file your license application on-line on web site www.wpc.dot.gov.in as soon as you received this letter. Yours faithfully,
To, The Assistant Wireless Advisor to the GOI Amateur Section, WPC Wing, 616, Sanchar Bhavan, 20, Ashoka Road, New Delhi – 110 001 Log on www.wpc.dot.gov.in for Guidelines / Forms / Rules & Regulations and other Amateur activities
Government of India Ministry of Communication & Information Technology Department of Telecommunication Wireless Monitoring Organisation IWMS, Perungudi, Chennai – 96 (Two copies of this page are to be submitted)
___________________________________
Date
____________________
To
____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Subject:- Result of Amateur Station Operators Certificate – Restricted Grade Exam held on ____________ at ____________________ Roll No: ______________ Sir/Madam, I am directed to inform you that:5) You have been declared successful in ______________________ Examination. The papers are being forwarded to the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT: 616, Sanchar bhavan, 20, Ashoka Road, New Delhi – 1100 001. As soon as the decision to grant the Amateur License is taken by the Ministry, you will be intimated by the Ministry accordingly. You are requested not to send any money or papers until unless it is asked for. 6) You have not qualified in the ______________________ Examination. 7) Communication regarding grant of license will be sent to you by the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT, New Delhi in due course. 8) You may file your license application on-line on web site www.wpc.dot.gov.in as soon as you received this letter. Yours faithfully,
To, The Assistant Wireless Advisor to the GOI Amateur Section, WPC Wing, 616, Sanchar Bhavan, 20, Ashoka Road, New Delhi – 110 001 Log on www.wpc.dot.gov.in for Guidelines / Forms / Rules & Regulations and other Amateur activities
ASOC EXAMINATION UNDERTAKING (To be issued by Parent/Guardian/Head of Institution of candidates aged between 12 to 18 years) To: Officer in Charge Wireless Monitoring Station
From:
I
…………………………………………,
Parent
/
Guardian
/
Head
of
Institution
of
……………………………………….. have no objection to his/her participation in Radio Amateur activities and experiments. I undertake responsibility ensuring there of. Yours faithfully, Place : Date:
Signature
Self verification Type of applicants ALL
Application form description
Main Application
Form Section / Particular to Filled First Name, Middle Name, Last Name correctly Date of birth column has been properly filled Filled exact location of station completely Have you signed the Declaration section and filled the place section Has you got a witness to sign the respective sections Have all sections been filled
(√)
(Fill not applicable when appropriate. Donot leave blank)
Nationality Proof
Personal Particulars
All Attestations
Age proof
Photos
Proof of Nationality attached (Tick the attached proof)
Have you attached Four copies of completely filled PP form Has the data filled in the PP form match that filled in Main Application form All four PP forms are indivudually signed by me Attestation is by proper gazetted officier Gazetted Officier seal is properly affixed Gazetted officer Name, Designation, Dept is properly written by attester himself / is present in the seal used Age proof document attached (Mention which of the 3 Birth Certificate / 10th MS / 12 MS) Name in the document completely matches with application name Date of birth column completely present Document has field description and data in English also It is attested by proper gazetted officer 2 copies of port sized photo (3 X 4cm ) included Both photos has my signature in the front which is visible Both photos has my Name written in the back
Properly filled Nationality certificate attached Attested copy of all data pages of my port attached
Independent verification (√)
Self verification Type of applicants
Application form description
Self addressed Envelope
Result sheet Date column in all forms For Minor applicants (Age between 12 - 19 Radio Theory and Practice exemptee
Parental consent form
Part 1 Exemption certificate holders
Form Section / Particular to Photos has been enclosed in a small transparent plastic cover and stapled in the front left hand corner of the application One envelope has been attached It is properly self addressed and unstamped It's size is 27 X 12 cm 2 copies of result sheet has been attached Name and address sections has been properly filled All dates have been entered in DD/MM/YYYY format Completely filled Parental consent form attached Parental consent form is signed by parent I have attached my BE/ME ECE degree certificate It is attested by proper gazetted officer
(√)
Independent verification (√)
1.Name:( In Capitals)
………………………………..……………………………………………………… (Last name) (First) (Middle)
2. Father's Name : and Address 3. Address (Present) :
4. Address (Permanent) : City/Town State Res. No. Mobile No. Personal Email
5. Date of Birth
(DD/MM/YYYY)
District PIN
Place of Birth
Nationality
Occupation
INDIAN (b) Exact location of the Station
6. (a) Category of licence applied for
(Including name of City, Dist, State & PIN)
7. Do you hold Radiotelegraph Operator's Certificate? If yes, give particulars: Name of the certificate
Cert. No.
8. Particulars of Amateur Station Operator's Examination:Name Centre
Date of Issue
Yes / No Validity
Month of Examination
9. Particulars of apparatus to be used: Manufacturer's Frequency Apparatus used` Name Type No. Range R.F. Power Output To Be Homebrewed or purchased after getting Licence Transmitter Receiver
Frequency Measuring Device
10. If appeared in any of the Amateur Station Operator's Examination. (If yes, indicate the date of the examination)
Yes / No
DECLARATION I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed there from. I also agree that in case any information given by me herein before is found false at a later date, the licence, if granted, will be cancelled. I further solemnly give an undertaking that I will not either directly or indirectly divulge to any person, except when lawfully authorised or directed to do so, the purport of any message which I may transmit or receive by means of any wireless apparatus operated by me or which may come to my knowledge in connection with the operation of said apparatus. I have carefully read and understood the rules contained in the Indian Wireless Telegraphs (Amateur Service) Rules, 1978 and undertake to abide by them and observe the conditions of the licence. The licensed station shall not be made accessible to any unauthorised person at any time. Signature of witness
Signature of applicant
Name (in block letters)
Name (in Block letters):
Address:
Date :
Date :
Place :
APPENDIX III NATIONALITY CERTIFICATE Certified that I have known Shri / Smt / Kum ____________________________________ son/daughter of Shri ______________________________
for the last _______ years and
that to the best of my knowledge and belief he/she bears a good moral character. He / She is of INDIAN nationality. He / She is not related to me. Address :
Signature:
Dated:
Designation : Office Seal (Should not be only in local language)
Note- This certificate should be from one of the officers listed below :1. Gazetted officers of Central or State Governments. 2. of Parliament or State Legislatures. 3. Sub-Divisional Magistrate/Officer. 4. Tahsildars or Naib/Deputy Tehsildars Authorised to exercise magisterial powers. 5. Principal / Head Master / Head Mistress of the recognized institutions (School / College) if applicant is a Bonafide student of that institution.
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 1. Name in full ( in block letters)
:
2. Date of birth
:
3. Place of birth
:
4. Age
:
5. Height
:
6. Colour of eyes
:
7. Complexion
:
8. Colour of hair
:
9. Identification marks
:
10. Full address (in block letters)
: Pin:
11. Occupation (Major work or profession for which you receive money) 12. Nationality 13. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
16. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 12. Name in full ( in block letters)
:
13. Date of birth
:
14. Place of birth
:
15. Age
:
16. Height
:
17. Colour of eyes
:
18. Complexion
:
19. Colour of hair
:
20. Identification marks
:
21. Full address (in block letters)
: Pin:
22. Occupation (Major work or profession for which you receive money) 12. Nationality 14. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
17. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 23. Name in full ( in block letters)
:
24. Date of birth
:
25. Place of birth
:
26. Age
:
27. Height
:
28. Colour of eyes
:
29. Complexion
:
30. Colour of hair
:
31. Identification marks
:
32. Full address (in block letters)
: Pin:
33. Occupation (Major work or profession for which you receive money) 12. Nationality 15. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
18. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Personal Particulars Form THE FOLLOWING DETAILS MAY ALSO BE FURNISHED (Four Copies of this page are to be submitted) 34. Name in full ( in block letters)
:
35. Date of birth
:
36. Place of birth
:
37. Age
:
38. Height
:
39. Colour of eyes
:
40. Complexion
:
41. Colour of hair
:
42. Identification marks
:
43. Full address (in block letters)
: Pin:
44. Occupation (Major work or profession for which you receive money) 12. Nationality 16. Father’s name and home address (Aliases if any)
:
Indian : Pin:
14. Particulars of previous applications if any made by the applicant for the issue of Amateur Licence
:
15. Type of Licence applied for
: Restricted Grade / General Grade
19. Exact location of station (Full address in block letters)
:
Pin:
Date:
(Signature of applicant)
Government of India Ministry of Communication & Information Technology Department of Telecommunication Wireless Monitoring Organisation IWMS, Perungudi, Chennai – 96 (Two copies of this page are to be submitted)
___________________________________
Date
____________________
To
____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Subject:- Result of Amateur Station Operators Certificate – Restricted Grade Exam held on ____________ at ____________________ Roll No: ______________ Sir/Madam, I am directed to inform you that:1) You have been declared successful in ______________________ Examination. The papers are being forwarded to the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT: 616, Sanchar bhavan, 20, Ashoka Road, New Delhi – 1100 001. As soon as the decision to grant the Amateur License is taken by the Ministry, you will be intimated by the Ministry accordingly. You are requested not to send any money or papers until unless it is asked for. 2) You have not qualified in the ______________________ Examination. 3) Communication regarding grant of license will be sent to you by the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT, New Delhi in due course. 4) You may file your license application on-line on web site www.wpc.dot.gov.in as soon as you received this letter. Yours faithfully,
To, The Assistant Wireless Advisor to the GOI Amateur Section, WPC Wing, 616, Sanchar Bhavan, 20, Ashoka Road, New Delhi – 110 001 Log on www.wpc.dot.gov.in for Guidelines / Forms / Rules & Regulations and other Amateur activities
Government of India Ministry of Communication & Information Technology Department of Telecommunication Wireless Monitoring Organisation IWMS, Perungudi, Chennai – 96 (Two copies of this page are to be submitted)
___________________________________
Date
____________________
To
____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Subject:- Result of Amateur Station Operators Certificate – Restricted Grade Exam held on ____________ at ____________________ Roll No: ______________ Sir/Madam, I am directed to inform you that:5) You have been declared successful in ______________________ Examination. The papers are being forwarded to the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT: 616, Sanchar bhavan, 20, Ashoka Road, New Delhi – 1100 001. As soon as the decision to grant the Amateur License is taken by the Ministry, you will be intimated by the Ministry accordingly. You are requested not to send any money or papers until unless it is asked for. 6) You have not qualified in the ______________________ Examination. 7) Communication regarding grant of license will be sent to you by the Assistant Wireless Advisor to the GOI, Amateur Section, WPC Wing, Ministry of Communication & IT, New Delhi in due course. 8) You may file your license application on-line on web site www.wpc.dot.gov.in as soon as you received this letter. Yours faithfully,
To, The Assistant Wireless Advisor to the GOI Amateur Section, WPC Wing, 616, Sanchar Bhavan, 20, Ashoka Road, New Delhi – 110 001 Log on www.wpc.dot.gov.in for Guidelines / Forms / Rules & Regulations and other Amateur activities
ASOC EXAMINATION UNDERTAKING (To be issued by Parent/Guardian/Head of Institution of candidates aged between 12 to 18 years) To: Officer in Charge Wireless Monitoring Station
From:
I
…………………………………………,
Parent
/
Guardian
/
Head
of
Institution
of
……………………………………….. have no objection to his/her participation in Radio Amateur activities and experiments. I undertake responsibility ensuring there of. Yours faithfully, Place : Date:
Signature
Self verification Type of applicants ALL
Application form description
Main Application
Form Section / Particular to Filled First Name, Middle Name, Last Name correctly Date of birth column has been properly filled Filled exact location of station completely Have you signed the Declaration section and filled the place section Has you got a witness to sign the respective sections Have all sections been filled
(√)
(Fill not applicable when appropriate. Donot leave blank)
Nationality Proof
Personal Particulars
All Attestations
Age proof
Photos
Proof of Nationality attached (Tick the attached proof)
Have you attached Four copies of completely filled PP form Has the data filled in the PP form match that filled in Main Application form All four PP forms are indivudually signed by me Attestation is by proper gazetted officier Gazetted Officier seal is properly affixed Gazetted officer Name, Designation, Dept is properly written by attester himself / is present in the seal used Age proof document attached (Mention which of the 3 Birth Certificate / 10th MS / 12 MS) Name in the document completely matches with application name Date of birth column completely present Document has field description and data in English also It is attested by proper gazetted officer 2 copies of port sized photo (3 X 4cm ) included Both photos has my signature in the front which is visible Both photos has my Name written in the back
Properly filled Nationality certificate attached Attested copy of all data pages of my port attached
Independent verification (√)
Self verification Type of applicants
Application form description
Self addressed Envelope
Result sheet Date column in all forms For Minor applicants (Age between 12 - 19 Radio Theory and Practice exemptee
Parental consent form
Part 1 Exemption certificate holders
Form Section / Particular to Photos has been enclosed in a small transparent plastic cover and stapled in the front left hand corner of the application One envelope has been attached It is properly self addressed and unstamped It's size is 27 X 12 cm 2 copies of result sheet has been attached Name and address sections has been properly filled All dates have been entered in DD/MM/YYYY format Completely filled Parental consent form attached Parental consent form is signed by parent I have attached my BE/ME ECE degree certificate It is attested by proper gazetted officer
(√)
Independent verification (√)
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