WIRELESS INSTITUTE OF AUSTRALIA

WESTERN AUSTRALIAN DIVISION INC

The Award Manager
W.I.A. W.A. Division
P.O. Box 10
West Perth 6872
WESTERN AUSTRALIA

Official Station
VK6WIA

Application Form for the ZONE 29 Award

I submit herewith my application for the Zone 29 Award.

Please display on my Award certificate, if successful, any special endorsement as applicable to the
rules and regulations for the Award. I enclose the required fee. I declare that my station has been
operated within the limitations of my amateur radio licence for the contacts below.

Name ..(Please Print) ................................................................................... Callsign ..............................

Address ........................................................................................................................Address .....................

................................................................................................................. Post Code ...............................

Signature .................................................................................... Date of Application .............................

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Certified by: Name ..(Please Print) .................................................................................... Callsign ...............................

Name ..(Please Print) .................................................................................... Callsign ................................