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Your name: Email address:
1. QSO with Call
Branding Iron Number #
and 10-10 Number #
2. Please submit your Call
YOUR 10-10 NUMBER # YOUR 10-10 DUES DATE
YOUR 10-10 NUMBER #
YOUR 10-10 DUES DATE
YOUR BRANDING IRON NUMBER #
Your Address
Your City / Country
Your State
Your Zip Code
Any comments? Please do not hit enter. Form does not like.
To receive a certificate mail this information to:
Daryl, N5SCA, 902 N Ridge, Lampasas, TX 76550
Plus $2.00 and 2 First Class Stamps local ($5.00 DX) to cover mailing.