New Request

Call sign (foreign license to validate, e.g. W1ABC)

Call sign (to renew, e.g. HI8ABC)

Call sign (e.g. HI8ABC) Current category Novice Technical General Superior Desired category Technical General Superior

Current category Novice Technical General Superior Desired category Technical General Superior

1. General information about the applicant

ID / Identification document Place of birth Date of birth (dd/mm/yyyy) Passport number (if applicable) Passport expiration date (dd/mm/yyyy) Do you reside in the Dominican Republic? Yes No Nationality Occupation Employer name

Residency Permit (if applicable)

Residency number Residency type Temporary Permanent Residency expiration date (dd/mm/yyyy)

Permanent address

Street Number Apartment No. Neighborhood Province Municipality Cell phone Fax

Temporary address in the Dominican Republic (if applicable - Portable HI)

Street Number Apartment No. Neighborhood Province Municipality

2. Length of stay (Portable HI)

Arrival date (dd/mm/yyyy) Departure date (dd/mm/yyyy)

3-6. Service and category

Service to operate Geographic area of operation Registration category Superior Technical General Novice Experimental Call sign (if already assigned, e.g. HI8XXX) Description of the radio equipment to be used

8. Declaration of the information provided

Name of the declarant (if different from the applicant, e.g. representative) Acting as Applicant Representative Place of declaration Day Month Year