Republic of the Philippines

Office of the President No

Commission on Information and Communications Technoloy Corruption &
NATIONAL TELECOMMUNICATIONS COMMISSION
NATIONAL CAPITAL REGION Red Tape
BIR Road, East Triangle, Diliman, Quezon City

APPLICATION FOR ( ) SELL

( ) TRANSFER OF OWNERSHIP

DATE: ______________________

1. Applicant: _______________________________________________________________________________
2. Mailing Address: _________________________________________________________________________
3. Telephone No.(s): ________________________________________________________________________
4. Buyer: __________________________________________________________________________________
Name/Company: _________________________________________________________________________
Address: ________________________________________________________________________________
Telephone No.(s): ________________________________________________________________________

5. Particles of Equipment
Make/Type/Model Serial Number Frequency Range Power Emission
________________ _______________ ________________ ______________ ______________
________________ _______________ ________________ ______________ ______________
________________ _______________ ________________ ______________ ______________
________________ _______________ ________________ ______________ ______________
________________ _______________ ________________ ______________ ______________
________________ _______________ ________________ ______________ ______________

6. Possess/ radio Station License No.(s) Date of Issue Call Sign

______________________________
______________________________
______________________________
______________________________
______________________________
____________________________
____________________________
____________________________
____________________________
____________________________
________________________
________________________
________________________
________________________
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7. Attachment:
a. Affidavit of Sale
b. Certified true copy of Radio Station License and/or Permit to Possess
8. CERTIFICATION

I HEREBY CERTIFY THAT, that above articles are true and correct and the radio station(s) has/have been constructed in
accordance with the prescribe standards and in conformity with the existing Radio Laws and Regulations, and that I shall be liable for any
willful false statements in this application under the Revised Penal Code. Further, this certify that the applicants has no pending
Administrative Case and/or unsettled Penal Fines/s with the National Telecommunications Commission. In the event that applicant has
pending Administrative Case/s and/or unsettled Penalty Fine/s with the NTC before the filing of this application will automatically
become null and void, without prejudice to the filing of criminal case against the signatory of this application form.

Res. Cert. No.: ____________________________ _______________________________

Issued at: ________________________________ Signature over printed name
Issued on: _______________________________ ____________________________
T.I.N.: _________________________________ Position/Official Capacity
____________________________
Tel/Cell No.