FORM # BTA-03
ROYAL GOVERNMENT OF BHUTAN
MINISTRY OF COMMUNICATIONS
BHUTAN TELECOM AUTHORITY

Application for grant of an Amateur Radio Licence for operation in Bhutan
(Foreign Nationals)

1.     Surname               :

2.     First Name            :

3.     Place of Birth        :

4.     Date of Birth          :

5.        Nationality           :

6.        Occupation         :

7.     Home Address      :

8.     Address in Bhutan :        BHUTAN HAM CENTRE, Thimphu

9.     Period of Visit
                       Start                :
                       Finish              :

10.   Details of VISA:
                       Date of Issue      :
                       Date of Expiry    :
                       Reason for Visit :

11.   Passport Details – give the following information:
                       Passport Number :
                       Date of Issue         :
                       Date of Expiry       :
                       Place of Issue       :

12.   Do you hold any amateur radio licence privileges in any country?
        If so, please supply the following information:
        a.    Call sign of Licence held  :
        b.     Licence Number (if any)  :
        c.     Class of Licence              :
        d.     Place and Date of issue  :
        e.     Country of Issue                :
        f.      Issuing Authority                :
        g.     Expiry date of Licence     :

        NOTE:        Attach 1 photocopy of current amateur radio lincence and any other amateur radio licence possessed by you.

13.   Location of Station in Bhutan        :        BHUTAN HAM CENTRE, Thimphu

14.   Details of amateur radio equipment to be used:

        a.        Manufacturer of equipment  :        Bhutan Ham Center will provide
        b.        Country of manufacture        :        Bhutan Ham Center will provide
                 i. Transceiver (tick)          :    YES/NO
                      If YES, please complete the following:
                ii.     Receiver Model No. : Bhutan Ham Center will provide
               iii. Transmitter Model No. : Bhutan Ham Center will provide
               iv. Power Output                : Bhutan Ham Center will provide

        What is the frequency control method of the proposed equipment (tick):
               a.               Variable Frequency Oscillator
               b.               Crystal Controlled
               c.               Phase Locked Loop
               d.               Digital Control

               Note:               Intended modes of Operation
                Morse Code         :        YES
                SSB                      :        YES
                RTTY                     :        YES
                SSTV                    :        YES
                OTHERS              :        YES

               Note:               Permitted Modes of Operation are stated in the terms and conditions of

                              the licence.

15.        Frequency Band of Operation
        a.        Frequencies of operation are given on the licence if issued
        b.        Frequencies are governed by the ITU Region 3 allocations and Bhutan National Radio Regulations 1999.

        IMPORTANT NOTE:        Out of Band operation is not permitted and will result in cancellation of the licence privileges.

16.        Aerials/Antennae to be used :        Bhutan Ham Center will provide

17.   Additional information if any       :        Bhutan Ham Center will provide

18.        DECLARATION:

        I, the applicant, do solemnly and sincerely declare that the information given on this Application Form is true and correct. It is also understood that all radio operation on the amateur radio bands must be made strictly in accordance with the licensing terms and conditions of the Ministry of Communications, Kingdom of Bhutan.

SIGNED                          :                        ___________________________________

Name in Block Letters  :

Date                                :