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: