Application for a Radio License

No.___________________

License required by

P.O.Box Telephone

Address: Region_______________ Zone: _____________ Woreda: _________ Kebele_________ H.No. ______

Reason for requesting license

Requested duration of license

TYPES AND DESCRIPTIONS COMMUNICATION RADIO EQUIPMENT

Manufacturer Model Power Serial No. Quantity

LOCATION OF RADIO STATION TYPE OF STATION

Region Zone Woreda Kebele Fixed, Mobile, Other

Air
Communication Links with Type of
Distance Frequency Emission Operating Time
possible configuration Antenna
(Km)

I hereby certify that, to the best of my knowledge, the information contained in this application form and
the  attached required documents are true in all respects and I  hereby give an undertaking that, upon a
grant of the communications radio license, I shall abide by the terms and conditions upon which the license
is  granted,  and  shall  not  transfer  to  any  third  party.  I  accept  that  my  license  may  be  revoked  and  the
appropriate  penalty  applied  if  it  is  established  that  I  have  been  granted  a  license  based  on  incorrect 
information, or I have transferred the communication radio to any third party. 

        Applicant’s Name        _________________________    

Applicant’s Signature and Seal________________________          Date __________________ 

Note: The Communications Radio equipment voice and data Transmission technique shall not be 
Encrypted.