Name Call

Address of Applicant:

Telephone number

Email Address

DX-pedition Callsign (if known)

DX-pedtion Destination

DX-pedtion Dates

IOTA reference number

IOTA Island Group name

Have you confirmed through the Radio Society of Great Britain that the island will count for IOTA? Yes No

Please list the operator's name, call and operating preferences. (Ex. CW, SSB, RTTY) that will be present on the island and involved in the IOTA expedition below. Please briefly describe the expedition experience of each operator involved in the expedition.

Please indicate how many stations will you operate during the expedition 1 2 More than 2

List equipment that is to be taken on the expedition including transmitters, amplifiers and antennas below.

How many days do you plan to operate? 1 2 3 4 5

How many hours during each day will you operate? <8 8-12 12-18 18-24

Will you qsl via the bureau Yes No

Please describe your travel plans to and from the island below.

Have you obtained permission to operate from the island and all necessary licensing from the appropriate governmental agency? Yes No

Will the operation be participating in any "Freeband" operating? Yes No

Do you need a QSL manager? Yes No

If no, where are you in the process? Please answer below.

What is your estimated budget for the expedition? Please be specific.

Is there adequate electricity available? If yes, how many hours per day is power available? If no what power source will you use? Please answer below.

What other support have you obtained for this expedition, if any?

Have you done any research about the island? (ex. weather, natives, animals) If so what was the reference used? (include any amateurs that can or have assisted)

What is your QSL route?