NTC Form No.:

Reference Na:

APPL-03Republic of the PhilippinesNATIONAL TELECOMMUNICATIONS COMMISSIONAgham Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR RADIO STATION LIGENSEINSTRUCTIONS: All blanks must be filled up properly. Put 'n/a' for items not applicable to you. upon

completion of the form submit this together with required/supporting documents. Print allentries in block or CAPITAL LETTERS

i-::j Govemment i::::j Non-carrier [:::]wPc; [:::] New !::::l Ren

GLASS OF STATION (s):

No. of Stations per Classification(s)

PRS i__--j Amateur i____jOthers:

NuMBER.OF YEARS;|---] One i.---i Tralo i---l Thr:ee

Land MobilePortable

Others

RepeaterFixed/Land Base (F)UFB)Fixed (FX)

Land Base (FB)

1 APPLICANT2 BUSINESS ADDRESS3 CONTACT NO (s)

4 $TATION LIG€$ISE I{O,

5 FREQUENCY (tES)

EMAIL ADD.:

(lf Ap$icable)

CH1CH2CH3

cH4cH5cH6

6 SERVICE AREA/ POINT OF COMMUNICATION i

7 PARTICUI ARg TRANSCEfiTER Et(lUlfi'lrEfTFfSTATtOf{: (For Nup FtsL onry. us6 sopaftfie Eheets if n6c€$ary)

:....;:;i;;,,.....,.....,........"-""-----n"--___----__----_-__-+_--__i TyperModel ! i --i'--*---- --- l ---*-----^-^i! Sedal Number i : i :

i BW& Efii-r6s'rod i i i i :

: Power OutDut ! i : : i: Tvia ^f lt-+---o ! !: Type ofAftcnna ! ! ; ; :

i Antenna Heism ! i : : i

: Anbnn. Pol.riz.tion i i i ! i

;4fl|tenft6.1ft i i i i

i Coordlnat€ i ! i i i

*For Mobile Station; Specify the Type of Vehicle and its Plate Number under Exact Location.

ai.....-.-...--.-.."t.iatu.euij.i.E'iiiici.{6i.--^],.--Fii,fieijij{'cs.tjF.eEHii}irftE-.-l..Expi.fAiiii::ii

I eERTIFGIITIO{I}

t HEREBY CER FY that the above entries are tru€ and conect, that the radio station(s) shall be instalted/constructed in accordance Wth the pr€scribed standards and in conformity with the existing Radio Laws andRegulations and that I shall be liable for any willfu false statements made in this application under the RevisedPenal CodE of the Philippines.

Authorized RepresentativeSignature over Printed Name of Applicant

Date

oRx^'i=AMOUNT:

i cAsHtER

,20-

PLEASE sEE BACK HEREoF FoR rHE REQuIREMENTS ro BE SUBMITTED i[a;;:l-Hl*t::::::::THIS FORM /S NOT FOR SALE AND CAN BE REPRODUCED

iITC REGIOML OFFICE NO.:

D|OCI.IN ENTARY REQWREN ENrc FOR S{.I#SS'O'VNEW ,

1 Duly Accomplished Form

2 Copy of Construcfion Pormit (lf Applicable) |

3 Copy of Business Permit/DTl/SEC Registation4 Copy of Permit to Possess

RENEWAL1 tlrly Accomplisherl Form

2 Originalcopy of Licenee to be renevysd

Office Address:Contact No.:Fax No.:E-mailAddress: