Your Call Sign: _________________ Frequency Being Monitored: _____________________ Mhz
Source of Interference: A Repeater Output An Individual Other: ___________________
Interfering with: A Repeater Output An Individual A Repeater Input A Link
Call Sign of station being interfered with (if repeater, give repeater call sign) :____________________
RECORD PAGE __________ _____________________________________________________ _________________________________ Signed Call Date WPRC Checked Date Form WPRC-104/0694