NTC Fom No.: APPL.

OS
Republic of the Philippines Reterence No:
NATIONAL TELECOMMUNICATIONS COMMISSION
Agham Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR SHIP RADIO STATION LIGENSE

INSTRUCTIONS: All blanks must be filled up propedy. Pttt 'n/a' for items not applicable to you. Upon
completion of the form submit this together with required/suppofting documents. Print all
entries in bloc? or CAPITAL LETTERS

rYPE: i-:::l New ili Ren NUMBER oF YEARS' [----ione !----irwo i---lrnr"e
1 APPLICANT
2 BUSINESS ADDRESS
3 CONTACT NO (s) EMAIL ADD.:
4 STATION LICENSE NO. VALIDITY : (lf Applicable)
5 r{ArrE oF vEsaEus&ilP M*R{NA RGGISFRATIOI*:
TYPE OF SHIP IMO NUMBER :

6 CALL SIGN GROSS TONAGE: YEAR BUILT:

8 HOMEPORT
7 ROUTE

11 CERTIFICATION
I HEREBY CERTIFY that the above entries are true and conect, that the radio station(s) shall be installed
/construeted in accordance with the prescribed standards and in conformity with the existing Radio Laws and
Regulations and that I shall be liable for any wiltfulfalse statements made in this application under the Revised
Penal.Code of the Philippines,

Authorized Representative Date

Signature over Printed Name of Applicant

DATE: .20

AMOUNT:

CASHIER

PLEASE SEE BACK HEREOF FOR THE REQUIREMENTS TO BE SUBMITTED

7-HlSFORtitt IS NOT FOR SAIE AND CAN BE REPRA,DaCED lRwision No.. i

E*iis:el!i.-:--::-i
DO C U N ENTARY REQIII RENE Nl'ls FOR SUAMSSTOT
NEW
1 Duly Acmmplished Form l

2 Letter of Intent address to the Director.

3 Applications fur Permit to Possess
4 Copy of Marina Certificab of Registration and Oirvnership
fupy of Commercial Radio Operatole Cefficets of Operator with a Certifpation of
"^ Emptoyment issued bythe' company

RENEWAL
1 Duly Accomplished Form
2 Adginalcopy d ticensetobemnemd

NTC REGIONAL OFFICE NO.

O,ffce Address
Contact No.
Fax No.
E-mailAddress