Would you like to add TA3NAG to the callsign database?

1) Information needed to be provided to be added to the database. This information needs to be provided in the layout below in order for your request to be processed.

MANDATORY
Callsign:
First Name + Middle initial:
Last Name:
Address Line 2: (City/Town etc)
Country:

OPTIONAL
Plus any other information you want:
Address Line 1: (Street etc)
Zip/Post Code:
Grid Square: (or Latitude & Longitude)
Previous Callsign(s):
CQ Zone:
ITU Zone:
IOTA Ref. Number: (AS-007 etc)
IOTA Group Name: (Honshu Island etc)
QSL Info:
Public Email:
Birth Year:
Show Birth Year on page?: Yes/No
eQSL?: Yes/No
LOTW?: Yes/No
Mail QSL?: Yes/No