ࡱ> q  H/bjbjt+t+ !AA0]FFFF8~2F*D D D D D RHxzzzzzz$uiD D D D *4D D x"$"xxxD <wy#FFxCivil Air Patrol Radio Station License Application Wing:  FORMTEXT ConnecticutRegion:  FORMTEXT NortheastCall Sign:  FORMTEXT      ALicensee Name:  FORMTEXT      Charter Number:  FORMTEXT      Grade:  FORMTEXT      CAPSN:  FORMTEXT      Street Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT CTZIP:  FORMTEXT      Home Phone:  FORMTEXT      Work Phone:  FORMTEXT      ROP # and Wing:  FORMTEXT        FORMTEXT CTEmail Address:  FORMTEXT      Duty Assignment:  FORMTEXT      Type of Application: FORMCHECKBOX  New FORMCHECKBOX  Modification FORMCHECKBOX  RenewalBClass of Station: FORMCHECKBOX  Fixed FORMCHECKBOX  Mobile FORMCHECKBOX  AirmobileType of Station: FORMCHECKBOX  Voice FORMCHECKBOX  Digital FORMCHECKBOX  Voice/DigitalTransmitter Location:CStreet Address or other description of site:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT CTZIP:  FORMTEXT      Latitude:  FORMTEXT      Longitude:  FORMTEXT      Equipment Information:DManufacturer/Model #Serial NumberOwnerPowerMode FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT      Emergency Power:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Type:  FORMCHECKBOX  Generator  FORMCHECKBOX  Battery  FORMCHECKBOX  OtherEIs all equipment crystal controlled and capable of meeting CAP/NTIA frequency tolerance standards?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoFIf the answer to this question is No, DO NOT submit this applicationAntenna Height Above GroundAntenna Height Above MountAntenna Mounted OnG FORMTEXT       FORMTEXT       FORMCHECKBOX  Ground FORMCHECKBOX  Building FORMCHECKBOX  Tower FORMCHECKBOX  OtherFCC Coordination Data:Nearest Airport:  FORMTEXT    Distance to Airport:  FORMTEXT      HDigital Operation:MYCALL  FORMTEXT      ALIAS  FORMTEXT      NODE  FORMTEXT      MAILBOX  FORMTEXT      IDigipeat Hours:  FORMTEXT      Amateur License:Class:  FORMTEXT      Callsign:  FORMTEXT      JCTWG Form 100-A (9/00) Previous editions are obsolete LEASE AGREEMENT FOR RADIO EQUIPMENTK I hereby offer to the Commander of the Connecticut Wing, Civil Air Patrol, for the use of official CAP business, the following items of equipment owned by me: (list transmitters and receivers)  FORMTEXT       I affirm that the equipment described is at this date, free of encumbrance of any kind, including claims, assessments, or secondary legal ownership by reason of minority. I distinctly understand that the terms of this agreement, the further use of CAP channels, assignment, supervision, and the control of the above equipment will be subject to the direction of the Commander of the Connecticut Wing, Civil Air Patrol, or his/her designee. It will be used for official business as set forth in the CAP Regulations and Directives. I further understand and agree that said equipment after such official use will be returned to me subject to reasonable wear and tear, acts of God, or any enemy. LMember Certification: This signature applies to the radio license application, and also to the above lease agreement when applicable. I certify that I am a current CAP member and that the information given herein is true to the best of my knowledge. Member in ChargeDate  FORMTEXT      MUnit Commander's Approval: License application for the station described herein is approved. Unit CommanderDate  FORMTEXT      NDirector of Communications Approval: License Application is:  FORMCHECKBOX  Granted  FORMCHECKBOX  Denied Director of CommunicationsDate  FORMTEXT       CTWG Form 100-A (9/00) Previous editions are obsolete. (Reverse) Guidelines for Completing the Radio Station Application Form Section A Fill in the following: Wing, Region, Name, Charter Number, Grade, CAPSN, Address, City, State, ZIP, Home Phone Number, Work Phone Number, ROP # and Wing (where ROP was issued). Section B Check one from each line. Section C Complete if different from the address in Section A. Complete Latitude and Longitude. (even if the request is for a mobile station) Section D List all equipment that may be used by you. Indicate whether the equipment is owned by you (Member) or CAP. Section E Check if applicable. (only for land stations) Section F This question must be answered. Section G If the application is for a mobile station, do not complete Antenna Height information, check Other for mount location. Section H Complete even is the application is for a mobile unit. Section I Complete only if the application is for a Digital or Voice/Digital station. Section J Complete if applicable. Section K List all radio equipment that is being offered for use in Civil Air Patrol. (should match member owned equipment listed in Section D) Section L Sign and date the application and submit to your unit communications officer. 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