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. Members 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. Fathers 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. Fathers 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. Fathers 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. Fathers 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:
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
verify
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 Passport 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 passport
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
verify
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
()
