NTC Form No.

: APPL-03
Republic of the Philippines Reference Na:
NATIONAL TELECOMMUNICATIONS COMMISSION
Agham Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR RADIO STATION LIGENSE

INSTRUCTIONS: 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 all
entries in block or CAPITAL LETTERS

i-::j Govemment i::::j Non-carrier [:::] PRS i__--j Amateur i____jOthers:

wPc; [:::] New !::::l Ren NuMBER.OF YEARS;|---] One i.---i Tralo i---l Thr:ee

GLASS OF STATION (s):

No. of Stations per Classification(s)
Repeater Land Mobile
Fixed/Land Base (F)UFB) Portable
Fixed (FX) Others
Land Base (FB)
1 APPLICANT
2 BUSINESS ADDRESS
3 CONTACT NO (s) EMAIL ADD.:
4 $TATION LIG€$ISE I{O, (lf Ap$icable)
5 FREQUENCY (tES) CH1 cH4
CH2 cH5
CH3 cH6
6 SERVICE AREA/ POINT OF COMMUNICATION i
7 PARTICUI ARg TRANSCEfiTER Et(lUlfi'lrEfTFfSTATtOf{: (For Nup FtsL onry. us6 sopaftfie Eheets if n6c€$ary)

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

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

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

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.fAii
ii
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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 and
Regulations and that I shall be liable for any willfu false statements made in this application under the Revised
Penal CodE of the Philippines.

Authorized Representative Date

Signature over Printed Name of Applicant

oRx^'i= ,20-
AMOUNT:

i cAsHtER

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

1 Duly Accomplished Form

2 Copy of Construcfion Pormit (lf Applicable) |
3 Copy of Business Permit/DTl/SEC Registation
4 Copy of Permit to Possess

RENEWAL
1 tlrly Accomplisherl Form
2 Originalcopy of Licenee to be renevysd

iITC REGIOML OFFICE NO.:

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