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TRANSCRIPT
NTC Form No.:
Reference No:
APPL-01
Republic of the PhilippinesNATIONAL TELECOMM UNICATIONS COMMISSIONAgham Road, East-Triangle, Diliman, Quezon City
APPUCATION FOR PERMIT TO :
i----_--i puRcHAsE i:--:_i rRANsMtrrER (s)
i:-_-::_1 PossEss i:::::i rRANscErvER (s|
fNSTRUCTIONS: All blanks must be filled up properly. Put 'n/a" for items not applicable to you. Uponcompletion of the form submit this togetherwith rcquiredlsuppofting documents. Print altenties in block or CAPITAL LETTERS
Type of Service :
i_____! Fixed and Land Mobile
i-----i Maritime
Nature of Service
Number of unit(s!
Repeater
i-:-:j Amateuri-----'iL____j Aeronautical
Fixed
tlttta
ttttll
alaltlcvll
lltl
Satellite
Broadcast
co
Special
Others
CP
ttlltl
tltlIt
tattll
Land Base Mobile Portable
1
234
5
APPLICANTBUSINESS ADDRESS
CONTACT NO(s)CPCN or PA No.
EMAIL ADD.:
PARTIGULARS oF EQUIPMENT(s): (use separate sheets if necessary)
INTENDED usE oF EQUTPMENT {s}: (check appropriate box)tl
i___-_! New Radio Station i i1--__J
l-_-_-! Additionat Radio Station i--lL-:::i Additionat Radio Equipment with
Change of Equipment
For Storage at:
Call Sign:
SOURCE OF EQUIPMENT(s):Name and address of Radio DealerDealefs Permit No.
Permit to Sell/transfer No.Others
For Permit fo Possess:
t!
i-__-_i Others :
Date lssued:Date lssued:
CERTIFICATION
I HEREBY CERTIFY that the above entries are true and conect, that the radio station(s) shall be installed /constructed in accordance with the prescribed standards and in conformity with the existing Radio Laws andRegulations and that t shall be liable for any willful false statements made in this application under the RevisedPenal Code of the Phitippines.
Authorized RepresentativeSignature over Printed Name of Applicant
Date
. - ------'liioRll;rei
AMOUNT:
It!ti--__-----------__--_c-*9-t!lEB----__-_-_-------i
PLEASE SEE BACK HEREOF FOR THE REQUTREMENTS TO BE SUBMITTED
rFlIS FORM /S ruOT FOR SAIE AND CAN BE REPRODUCED
lKeuston No,: !
iReugion Date: iL-------------______I
A.r FrxED AND MOBTLE LAND SERVTCES (FXLMI (CV/CO)l-l 1 Letter of Intent
tf 2 Duly accomplished application form for Permit to Purchase /Possess
u 3 Copy of SEC Registration / DTI
I | 4 Copy of valid Mayofs / Business Permit
I I 5 Network Diagram with geographical coordinates of the stations.
A.2 FTXED AND MOBILE LAND SERVTCES (CPy SATELLITE SERVICE1 Letter of tntent
n 2 Duly accomplished application form for Permit to Purchase /Possess
tf 3 Original Technical Plans signed and sealed by a duly licensed Professional Electronics and Communications
DACUMENTARY REQUIREMENTS FOR SUBIL|ISSIOfV; PERMIT rO POSSESS
1 Original copy of the Permit to Purchase2 Copy of Official Receipt
DOCUMENTARY REQUIREMENTS FOR SUBJtt SSTON : PERMTT TO PURCHASEA F|XED AND MOBTLE LAND SERVTCES (FXLM)
Engineer (PECE), to wit:
a Physical lay-out of station (Floor Plan)
b Network Diagram with geographiocal coordinates of station (s)
c Map showing exac;t address of station (s)
d Antenna System Plan (type, gain, radiation pattem, height)e Equipment specificationsl brochures
1 For VSAT ( Transponder Lease Agreement & Certification from Satellite Provider)
B AMATEUR SERVICES8.1 RADIO CLUB STATION LICENSE
[-l 1 Letter of IntenURequest addressed to the Regional Director
n 2 SEC Registration/Artictes of lncorporation3 List of Board of Directors, Club Station Trustee, and at least 15 licensed members
f-] 4 Copy of Certificate of Recognition from PARA.
tf 5 Duly Accomplished application forms signed by the Club PresidenUAuthorized Representative
8.2. REPEATER STATION LICENSE
l-l 1 Letter of Intent
f'] 2 Duly accomplished Application Forms Permit to Purchase/Possess
I I 3 Copv of Amateur Club Radio Station License
f-l a Copy of club resolution designating the trustee and the names of not more than 3 control operators.
tl 5 Copy of the amateur radio license of the trustee and control operators
8.3 STATION LICENSE
n 1 Copy of Verified Report of Ratings
[-| 2 Duly accomplished application form for Permit to Purchase I possess
l_J 3 Duly accomplished Information Sheet
c. clvrc AciloN RADIO SERVICESC.1 RADIO GROUP CLUB
n 1 Letter of Intent
f-l 2 Copy of SEC Registration/Articles of Incorporation3 List of Licensed Officers and Trustee and at least 50 Licensed active members
|-| 4 Duly Accomplished application forms signed by the Group PresidenUAuthorized Representative
C.2 INDIVIDUAL STATION LICENSE
tl 1 Copy of Verified Certificate of Membership
I I 2 Copy of Radio GrouP License
tf 3 Accomplished application form for Permit to Purchase
I | 4 Application of RLM Certificate
t_] 5 Duly Accomplished Information Sheet
D. MARITIME SERVICES1 Letter of lntent
n 2 Accomplished application form for Permit to Purchase
l-_l 3 Copy of Certificate of Vessel Registry from MARINA'
f-l 4 Copy of Certificate of ownership from MARINA
f.] 5 Valid Radio Operator's Certificate with certificate of employment
E. AERONAUTICALSERVICESn 1 Letter of Intent
[-l 2 Accomplished application form for Permit to Purchase / Possess
f-l 3 Copy of Certificate of Registration with CAAP
[-l 4 Copy of Radio Electronic and Instrument Inspection Report of aircraft
[-l 5 Copy of Certificate of Airworthiness
f-l 6 Valid Radio Operator"s Certificate with certificate of employment
t] 7 Frequency Clearance for Fixed Aeronautical Station
F. OTHER SERVICES
n 1 Letter of Intent
n 2 Accomplished application form for Permit to Purchase / Possess
n 3 Network Diagram with geographical coordinates of the stations.
|-| 4 Equipment specifications/ brochures
NTC REGIONAL OFFICE NO.:Ofiice Address:Contact No.:Fax No.:E-mail Address: