Repeater/Beacon/Link etc. NZART FORM 10
(revised: 2010-06-01)
Please fill in the details and send by email to: fmtag@nzart.org.nz
Application date:
Originating Branch name and number:
Trustees (two required)
Trustee 1	(also the nominated MED contact person)
Name:
Callsign:
NZART membership number (on Break-In wrapper):
Phone number:
Email address:
Trustee 2
Name:
Callsign:
NZART membership number (on Break-In wrapper):
Phone number:
Email address:
Location in NZ2000 Metric Grid coordinates:
MED site name, or name on NZ2000 map:
Site ground height on NZ2000 map:
Desired name of station in Call Book:
Owner of site:
Owner of building housing station:
Are there “Suppressed Records” services at or near the site?	YES	NO
Type of station: Amateur H
Voice repeater (Y/N):				Digipeater (Y/N):
Data repeater (Y/N):				ATV Repeater (Y/N):
National System repeater (Y/N):		STSP repeater (Y/N):
Beacon (Y/N):		Beacon callsign requested:
Other (give details):
Band for this station:
Receive location: Amateur Mobile Area
Antenna configuration:
Antenna polarisation:
Antenna gain (dB isotropic):
Antenna height above ground (m):
Distances to other nearby antennas (m):
Direction(s) of maximum radiation (degrees true), or omni:
Feeder loss (dB) or feeder type and length:
Transmit circulator make and model number:
Transmit Duplexer or Output Filter make and model number:
Transmit Duplexer or Output Filter loss (dB):
Transmit modulation mode:
Receive Duplexer or Input Filter make and model number:
Receive Duplexer or Input Filter loss (dB):
Receive modulation mode:
Make of Tx:					Model of Tx:
Make of Rx:					Model of Rx:
Transmitter output power (W):		dBW		EIRP:		dBW
Main Power source Mains (Y/N):	Solar (Y/N):
Other (Y/N):				Backup power source (Y/N):

Copy of minutes of Branch meeting approving construction:
Comments and/or System diagram/description:

Details checked by MED-Approved Radio Certifier/Engineer number:
Please make payment of $50 to NZART HQ, by cheque or to BNZ Upper Hutt:
02 0772 0209760 00	Please email FMTAG when payment has been made:
fmtag@nzart.org.nz