2009   CQ-WE   PARTICIPANT SCORE SHEET   (PLEASE PRINT)


Full Name: _____________________________  Call: _____________  Class:_______

Work Address: ____________________________  Home:___________________________

  Room/Dept:  ____________________________       ___________________________

              ____________________________       ___________________________

              ____________________________       ___________________________

      Phone:  ___________________________     Phone:________________________

  Email Address: _______________________________________


The Exchange that you sent in the Contest:

  Name ___________________  Location Code ___________  Years Service _______
                         (Example:  ROB  CB  23)

  + If you are retired, check here: _____
  + If you operated the entire contest QRP, check here: _____
  + If you would like a paper 'Participation Certificate', check here: _____
      and send $3 to NAME of HOST CONTACT
                     123 ADDRESS of HOST
		     CITY, ST  ZIP
      Otherwise, an electronic certificate suitable for printing
      locally will be mailed to the email address supplied above.
  + If you would like us to consider activating a new Location Code
      for next year's contest, please list it here:                   ______



    --------------------  MY SCORES ARE  -------------------------------


       Sum of Yrs Svcs   x   Locations Worked   =     Total Score
      Worked This Mode*        This Mode**             This Mode

CW     _______________   x   ________________   =   _________________

PHONE  _______________   x   ________________   =   _________________

RTTY   _______________   x   ________________   =   _________________


                                       Total Score  _________________

*  The sum of the "Yrs Svc" from all stations worked in this mode.
** The # of Loc Codes worked in this mode from corresponding Check Sheet.

The log, location check sheets, and this score sheet submitted are to
 my knowledge honest and accurate.

Signature: _____________________________________  Date:_______________
(Please make any additional comments on the reverse side of this page.)