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License Application Worksheet
for Two Way Radio Systems
Applicant Information
Legal Name of
Applicant? (Name to appear on License) |
|
Applicant
is a (check one only please) [
] Corporation [ ] LLC
[ ] Government Entity
[ ] Individual
[ ] Partnership [ ] Other
(please specify)
|
Applicant
Nine Digit Federal Tax
ID Number (SSN or EIN)? |
|
Contact Person? |
|
Telephone Number? |
|
Fax Number? |
|
Mailing Street Address? |
|
Mailing Suite, Box
Number, Etc.? |
|
Mailing City, State,
& Zip? |
|
Applicant’s eMail
Address? |
|
Radio Dealer’s
Name? |
|
Radio Dealer’s
Contact Person? |
|
Which
party do we notify regarding frequency assignment ? |
[ ] Applicant
[ ] Dealer |
Application Type
Is this application for
a: [ ] New Station [
] Modification |
If a
modification, what
is the existing Call Sign? |
What modifications are
to be made? |
| |
Does the
applicant hold any other FCC licenses? [
]
Yes [
] No
[ ]
Don't Know |
License Type
This
application is for? |
Repeater/Mobile |
Repeater
Wattage |
Antenna Gain |
Base/Mobile |
Base Wattage |
Antenna Gain |
Mobile/Portable
Only |
Mobile/Portable
Wattage |
Other?
(Please Describe) |
| Will this system have
Telephone Interconnect?*
[ ]
Yes [
] No |
| *(Interconnected
to Public Telephone System: FCC Regulatory Fees may be assessed.) |
Location
In
the spaces below, provide Transmitter
Street Address; OR Nearest Major Intersection and Distance from Intersection? |
| |
City |
County |
State |
|
In the spaces below, please
provide Coordinates, Elevation and Height Above Average Terrain if known. (Not Required) |
Latitude |
Longitude |
Elevation FT |
HAAT
|
Antenna Information
What
type of structure supports
the antenna? [
] Building
[ ]
Tower
[ ]
Other _______________________________________________ |
Building
or tower height (in feet) ? (A) |
Height
of antenna only (in feet) ? (B) |
Overall
Height (structure plus antenna, in feet) (A+B) |
Are
there any existing call signs at this site?
[ ]
Yes [
] No |
If
Yes, please provide a current call sign. |
Is
this site filed with the FAA? [
]
Yes [
] No |
|
Is an Airport
located within Five Miles of this site?
[ ] Yes
[ ] No |
In
the spaces below, please provide the antenna site owner’s name and phone number. |
Name: |
Phone Number: |
Units
Number of
Mobile Units? |
Mobile
Wattage? |
Number of
Portable Units? |
Portable
Wattage? |
Number of
Pagers? |
Area of
operation in miles? |
Frequency
Eligibility and Misc.
This system
will be used for : [ ]
Voice [
] Data
[ ]
Both Voice and Data |
| In
the space below, briefly
describe the purpose of the radio system…nature of business, governmental
organization, Police, Fire, etc…. |
| |
| List control
stations meeting the 20’ rule and/or other misc. information in the spaces below: |
| |
| Comments /
Special Instructions: |
| |
All information requested is REQUIRED by the FCC in order
to obtain an FCC radio license.
Please fill in all information completely. If you need any assistance at
all, please call our office.
We’re glad to help!
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