Form FCC Form 312-R FCC Form 312-R Application for Renewal of Radio License in Specified Se

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Approved by OMB
3060-1066
FORM 312-R APPLICATION
FOR RENEWAL OF RADIO LICENSE IN SPECIFIED SERVICES
FOR OFFICIAL USE ONLY

APPLICANT INFORMATION
Enter a description of this application to identify it on the main menu:
1. Applicant
Name:

Phone Number:

DBA Name:

Fax Number:

Street:

E-Mail:

City:

State:

Country:

Zipcode:

-

Attention:
2. Contact
Name:

Phone Number:

Company:
Street:

Fax Number:
E-Mail:

City:

State:

Country:

Zipcode:

Attention:

Relationship:

-

RENEWAL INFORMATION
3. Rulepart under which this filing is made

Rulepart 23

4. Is a fee submitted with this application?

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If Yes, complete and attach FCC Form 159.
If No, indicate reason for fee exemption (see 47 C.F.R.Section 1.1114).
Governmental Entity

Noncommercial educational licensee

Other(please explain):
5. Application is for renewal of license in exact conformity with the existing license as specified below:
(a)File Number
(c)Call Sign
(e)Nature of Service
(g)Expiration Date

(b)Date Issued
(d)Location
(f)Class of Station
Petition to reinstate:

6. Note any changes such as discontinuance of use of a frequency, or of a type of emission or of a transmitter which have been made
since the last application covering this station was filed:

Items 7(a) and (b) apply to Part 21 licenses only.
Yes
7(a) Has there been removal of equipment or alteration of facilities as to render the Station not operational?

No
N/A

If YES when:
(b) If this is a Multipoint Distribution Service (MDS) station, is there a ownership interest in control
by, affiliation with, or leasing arrangement with a cable television company?

Yes
No
N/A

8. Applicant represents that there has been no change in applicant's organization and that there has been no transfer of control or
changes in the applicant's relation to the station, or financial responsibility; that applicants most recent application or report
embodying this information, as identified below, is to be considered as a part of this application, and the truth of the statements
therein contained is hereby reaffirmed. Note here any further exceptions, not already covered in question 6 or 7.

File Number Date

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9. Would a Commision grant of this application come within 47 CFR 1.1307, such that it may have a significant
environmental impact?

Yes
No
N/A

If YES, attach as an Exhibit an Environmental Assessment required by 47 CFR 1.1311:
If NO, Explain briefly why not:
10. Certification: The applicant certifies that, in the case of an individual applicant, he or she is not subject to a
denial of federal benefits pursuant to section 5301 of Anti-Drug Abuse Act of 1988, 21 U.S.C. 853a, or, in the case of a
nonindividual applicant (e.g., corporation, partnership or other unincorporated association), no party to the
application is subject to denial of federal benefits pusuant to that section. For the definition of a "party" for these
purposes, see 47 CFR 1.2002(b).

Yes
No

a. Applicant waives any claim to the use of any particular frequency or of the electromagnetic spectrum as against the
regulatory power of the United States because of the previous use of the same, whether by license or otherwise, and
requests a station license in accordance with this application. Applicant acknowledges that all attached exhibits are a
material part hereof.
b. The undersigned, individually and for the applicant, hereby certifies that the statements made in this application
are true, complete and correct to the best of the signer's knowledge and belief, and are made in good faith.
11. Designate Appropriate Classification:
Individual
Unincorporated Association
Partnership
Corporation
Governmental Entity
Other (please specify)
12. Please supply any need attachments.
1:

2:

3:

CERTIFICATION
13. Typed Name of Person Signing

14. Title of Person Signing

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WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND / ORIMPRISONMENT
(U.S. Code, Title 18, Section1001), AND/OR REVOCATION OF ANY STATIONAUTHORIZATION
(U.S. Code, Title 47, Section312(a)(1)), AND/OR FORFEITURE (U.S. Code,Title 47, Section 503).

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT
The public reporting for this collection of information is estimated to average 2.25 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
required data, and completing and reviewing the collection of information. If you have any comments on this
burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the
Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-1066), Washington, DC 20554. We
will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet
if you send them to [email protected]. PLEASE DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.
Remember - You are not required to respond to a collection of information sponsored by the Federal government,
and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control
number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of
3060-1066.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44
U.S.C. SECTION 3507.

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