Form JARL 96-04

INFORMATION REQUIRED FOR APPLICATION TO OBTAIN
A JAPANESE AMATEUR RADIO LICENSE

JARL-96-04Rev1
for non-Japanese only

( ) New Station

( ) Modification

Your E-Mail Address:

1.NAME OF APPLICANT:

2.DATE OF BIRTH:

3.NATIONALITY:

4.MAILING ADDRESS (in your home country):

5.This column is intentionally blank.

6.JAPANESE MAILING ADDRESS (where you can receive mail in Japan):

Tel:
Fax:

7.ADDRESS WHERE YOU WILL INSTALL YOUR STATION:

Tel:
Fax:
( ) FIXED and/or ( ) MOBILE/PORTABLE

8.CALL SIGN IN
HOME COUNTRY:

9.LICENSE CLASS:

10. DATE OF ISSUE AND EXPIRATION OF LICENSE:

11.PASSPORT NUMBER (if available):

12a. ESTIMATED DATE OF ARRIVAL IN JAPAN:

12b. ESTIMATED DATE OF DEPARTURE FROM JAPAN:

13.DESIRED BANDS, POWER, MODES AND EQUIPMENT DURING OPERATION IN JAPAN:
(Cross out choices not desired)