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                        ARRL INTERNATIONAL DX CONTEST
  
                                    [] CW
                                    [] PHONE  
  
CALL USED ______________________________  ARRL SECTION or COUNTRY_______________
  
CALL OF OPERATOR IF DIFFERENT FROM CALL USED____________________________________
  
CHECK ONE:                                                    
                                                Valid QSOs      MULTIPLIERS   
  [] Novice/Technician                 +-------------------------------------+
                                       | 160 |               |               |
Single Operator                        |-------------------------------------|
                                       |  80 |               |               |
  [] All Band                          |-------------------------------------|
  [] Single Band (circle one)          |  40 |               |               |
     160  80  40  20  15  10           |-------------------------------------|
  [] QRP (5W or less output)           |  20 |               |               |
  [] Assisted                          |-------------------------------------|                                                    
                                       |  15 |               |               |
Multioperator                          |-------------------------------------|
                                       |  10 |               |               |
  [] Single transmitter                |=====================================|
  [] Two transmitter                   |Total|               |               |
  [] Unlimited                         +-------------------------------------+
  
If multioperator, list calls of all operators and loggers:
  
_______________________________________________________________________________
  
Please enclose log, photos, comments, ideas, etc. with your entry and mail
promptly to: ARRL Contests, 225 Main Street, Newington, CT 06111.
  

_____________ X 3 = _____________ X ____________ = ___________________________ 
 Valid QSOs          QSO Points     Multipliers           Claimed Score
  
POWER OUTPUT:   [] 5 watts or less    [] 6-150 watts    [] Over 150 watts
  
+------------------------------------------------------------------------------+
| Club participation?   Yes_____  No_____                                      |
| ARRL Affiliated Club:________________________________________________________|
+------------------------------------------------------------------------------+
  
"I have observed all competition rules as well as all regulations for Amateur 
Radio in my country. My report is correct and true to the best of my knowledge.
I agree to be bound by the decisions of the ARRL Awards Committee."
  
Date ______________ Signature _______________________________ Call _____________
  
Print or type:
  
NAME_____________________________________ CALL______________
  
ADDRESS_____________________________________________________
  
____________________________________________________________