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  1.                                                                       A    
  2.  
  3. ___________________________________________________________________ R   R ______
  4.                           (Do not write above line)                         
  5.                                                                       L      
  6.                         ARRL INTERNATIONAL DX CONTEST
  7.                                     [] CW
  8.                                     [] PHONE  
  9.   
  10. CALL USED ______________________________  ARRL SECTION or COUNTRY_______________
  11.   
  12. CALL OF OPERATOR IF DIFFERENT FROM CALL USED____________________________________
  13.   
  14. CHECK ONE:                                      Valid QSOs      MULTIPLIERS                                
  15.                                        +-------------------------------------+
  16.   [] Novice/Technician                 | 160 |               |               |
  17.                                        |-------------------------------------|
  18. Single Operator                        |  80 |               |               |
  19.                                        |-------------------------------------|
  20.   [] All Band                          |  40 |               |               |
  21.   [] Single Band (circle one)          |-------------------------------------|
  22.      160  80  40  20  15  10           |  20 |               |               |
  23.   [] QRP (5W or less output)           |-------------------------------------|
  24.   [] Assisted                          |  15 |               |               |
  25.                                        |-------------------------------------|
  26. Multioperator                          |  10 |               |               |
  27.                                        |=====================================|
  28.   [] Single transmitter                |Total|               |               |
  29.   [] Two transmitter                   +-------------------------------------+
  30.   [] Unlimited                         |HOURS OPERATED|                      |
  31.                                        +-------------------------------------+  
  32. If multioperator, list calls of all operators and loggers:
  33.   
  34. _______________________________________________________________________________
  35.  
  36. Please enclose log, photos, comments, ideas, etc. with your entry and mail
  37. promptly to: ARRL Contests, 225 Main Street, Newington, CT 06111.
  38. Upload to BBS: 203-665-0090          Internet: contest@arrl.org
  39.  
  40. _____________ X 3 = _____________ X ____________ = ___________________________ 
  41.  Valid QSOs          QSO Points     Multipliers           Claimed Score
  42.   
  43. HOURS OPERATED: ______ POWER OUTPUT: [] 5 watts or less [] 6-150 watts [] Over 150 watts
  44. +------------------------------------------------------------------------------+
  45. | Club participation?   Yes_____  No_____                                      |
  46. | ARRL Affiliated Club:________________________________________________________|
  47. +------------------------------------------------------------------------------+
  48.  
  49. "I have observed all competition rules as well as all regulations for Amateur 
  50. Radio in my country. My report is correct and true to the best of my knowledge.
  51. I agree to be bound by the decisions of the ARRL Awards Committee."
  52.   
  53. Date ______________ Signature _______________________________ Call _____________
  54.   
  55. NAME_____________________________________ CALL______________
  56.   
  57. ADDRESS_____________________________________________________
  58.  
  59. ____________________________________________________________
  60.