Field Day

1. Field Day Call Used _______________

2. Club or  group name ____________________________________________________

3. Field Day location  ____________________________________________________

4. Check if you began   5. Number of people     6. Number of trans-
   set-up prior to         participating in        mitters in simul-
   1800 UTC Saturday. __   this operation.  ___    taneous operation. _____

7. ARRL/Canadian Section _____________  

8. Entry Class
   (check one only)

  __ A. Club or non-club      11. *---------------------------------------*
                                  |        CW         #       PHONE       |
  __ B. Non-club portable         |-------------------#-------------------|
       1 op ___                   |     QSOs  |PWR OUT#     QSOs  |PWR OUT|
       2 op ___                   |---|-------|-------#---|-------|-------|
       List operators             |160|       |       #160|       |       |
       __________________         |---|-------|-------#---|-------|-------|
                                  | 80|       |       # 80|       |       |
 __ C. Mobile                     |---|-------|-------#---|-------|-------|
                                  | 40|       |       # 40|       |       |
 __ D. Home Station               |---|-------|-------#---|-------|-------|
       (commercial power)         | 20|       |       # 20|       |       |
                                  |---|-------|-------#---|-------|-------|
 __ E. Home Station               | 15|       |       # 15|       |       |
       (emergency power)          |---|-------|-------#---|-------|-------|
                                  | 10|       |       # 10|       |       |
9. Power Source                   |---|-------|-------#---|-------|-------|
                                  |  6|       |       #  6|       |       |
 __ Generator         __ Battery  |---|-------|-------#---|-------|-------|
 __ Commercial Mains  __ Other    |  2|       |       #  2|       |       |
                                  |---|-------|-------#---|-------|-------|
10. Call sign of Novice/Technician| OTHERS            # OTHERS            |
   station (class 2A and above)   |___________________#___________________|
   ____________                   |   |       |       #   |       |       |
                                  |   |       |       #   |       |       |
                                  |---|-------|-------#---|-------|-------|
12. Total                         |   |       |       #   |       |       |
                                  |   |       |       #   |       |       |
  CW QSOs _____ X 2 = _________   *---------------------------------------*
                                  *---------------------------------------*
                                  |           |  CW   #           | Phone |
  Total                           |           | QSOs  #           | QSOs  |
                                  |-----------|-------#-----------|-------|
  Phone QSOs ____ X 1 = _______   |           |Novice #           |Novice |
                                  |           |CW QSOs#           |Ph.QSOs|
                                  |-----------|-------#-----------|-------|
  Total QSO points      ________  |           | Total #           | Total |
                                  |           |CW QSOs#           |Ph.QSOs|
                                  *-------------------#-------------------*

13. Total QSO points _______ X Power Multiplier (5W or less, X5; 150W or

    less, X2; over 150W, X1)   _______  equals Claimed Score (less

    bonus points)  ___________

14. Bonus Points            __ 100% Emergency Power   __ Messages handled 
                                                        (no.) ________   
    Attach proof required   __ Media Publicity                            
    for all bonus points                              __ Satellite        
    claimed. All bonus      __ Location in a                              
    points will be added       public place           __ Natural  Power   
    at ARRL HQ                                                            
                            __ Information booth      __ Packet Radio    
                                                                         
                            __ Message to SM          __ VHF/UHF 
                                                     
                            __ W1AW Field Day message __ Other _________

15. This certifies that the station whose call appears above was operated
    in accordance with the current field day rules and that, to the best of
    my knowledge, the points and scores set forth in the above summary are
    correct and true. This station was operated in accordance with FCC
    rules and regulations. I agree to be bound by any decision of the ARRL
    Awards Committee.

Date _________  Signed ________________________ Call __________
                     signature/call of club president

16. Full mailing address (please print)

Name    _______________________________

Address _______________________________

        _______________________________