Worksheet for FCC License Application

If Preparer information is the same as that of the Applicant, skip to item eight ( 8 ) .

(3) Preparer's Telephone Number

(6) Preparer's Physical Address
include City, State, & Zip Code 
(NO P.O. BOXES)

(7) Preparer's Mailing Address
include Street or PO Box, City, State, & Zip Code

Applicant's Information

(8) Applicant's Legal Name

(9) Applicant's Federal Tax ID Number:
If Individual = Social Security Number
Company or Governmental Entity= Employer Identification Number

(10) Name of Applicant's Contact Person

(11) Applicant's Telephone Number

(12) Applicant's FAX Number

(14) Applicant's Physical Address
include City, State, & Zip Code 
( NO P.O. BOXES)

(15) Applicant's Mailing Address
include City, State, & Zip Code
(P.O. Box acceptable)

(16)  Name of Radio Dealer

(19) Dealer's FAX Number

(20) Dealer's email Address

(21) Who do we contact regarding  frequency and / or emission issues?

(     ) Applicant           (     ) Dealer

(22) This application for a:  (     ) New Station     (     ) Modification     (     ) Renewal

(23) In the case of a modification or renewal, what is the existing Call Sign?

(24) In the case of a modification, what modifications are required?

(25) Does the applicant hold any other current FCC licenses?    (   )  Yes       (   ) No      (   ) Don't Know

(26) If the applicant holds any other current licenses, list associated call signs.

(27) Is Telephone Interconnect required for this system?* 
       (* FCC Regulatory Fees may apply for Interconnection to the Public Switched Telephone Network)

(     )  Yes            (     ) No

(28)  This application is for?  (  ) Repeater   (  ) Base Station   (  )  Mobiles   (Check all that apply)

(28A)  Repeater

Repeater Wattage

Antenna Gain

(28B)  Base

Base Wattage

Antenna Gain

(28C)  Mobiles/Portables 

Mobile/Portable Wattage

(28D)  Other? (Please fill in details in NOTES area.)

NOTES:

In the spaces below (29 - 32), If known, provide Transmitter Street Address; OR Nearest Major Intersection and Distance from Intersection?

(30)  City

(31)  County

(32)  State

In the spaces below, if known, please provide Coordinates, Elevation and Height Above Average Terrain.

(33)  Latitude (N)
(in Deg-Min-Sec NAD83)

(34)  Longitude (W)
(in Deg-Min-Sec NAD83)

(35) Site Elevation in Ft.

(36)  Height Above Average Terrain:

(39)  If other, Please specify:

(40)  Building or support structure ONLY height (in feet) ? (A)

(41)  Length of antenna only (in feet) ?   (B)

In the spaces below, please provide the antenna site owner’s name and phone number.

(43) Name:

(44) Phone Number:

(50) This system will be used for : (     ) Voice Only    (     ) Data  Only   (     ) Both Voice and Data

In the space below (51), briefly describe the purpose of the radio system…nature of business; ie: If governmental organization, Police, Fire, etc….

(52) Specify Frequency Range Below or List any Preferred Frequency:

VHF

UHF

UHF Offset

Low Band

800 MHz.

900 MHz.

Are your radios Narrowband Type Accepted by the FCC?  (   )  Yes    (   ) No   (   ) Uncertain

(53) Do you want to Monitor Frequencies?         (     )  Yes            (     ) No

(54) List control stations meeting the 20 Mtr. rule and/or other misc. information in the spaces below: