Form FCC Form 405 FCC Form 405 Application for Renewal of Experimental Radio Station Li

FCC 405 FEDERAL COMMUNICATIONS COMMISSION Approved by OMB

3060-0093

Est. Avg. Burden

Per Response:

2 Hrs 15 Min

APPLICATION FOR RENEWAL OF EXPERIMENTAL RADIO STATION LICENSE

NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to range from 30 minutes to 4 hours per response, with an average of 2 hours and 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection of information, including suggestions for reducing the burden to Federal Communications Commission, AMD-PERM, Washington, DC 20554, Paperwork Reduction Project (3060-0093). We will accept your PRA comments via email if you send them to [email protected]. DO NOT SEND COMPLETED APPLICATION FORMS TO THIS ADDRESS.

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 OMB control number 3060-0093.

The solicitation of personal information requested in this form is authorized by the Communications Act of 1934, as amended. The Commission will use the information provided in this form to determine whether grant of this application is in the public interest. If we believe there may be a violation or potential violation of a statute, regulation, rule or order, your application may be referred to the appropriate Federal, state, or local agency responsible for investigating, prosecuting, enforcing or implementing the statute, rule, regulation or order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government, is a party to a proceeding before the body or has an interest in the proceeding.

As of December 3, 2001, all parties and entities doing business with the Commission must obtain a unique identifying number called the FCC Registration Number (FRN) and supply it when doing business with the Commission. Failure to provide the FRN may delay the processing of the application. This requirement is to facilitate compliance with the Debt Collection Improvement Act of 1996 (DCIA). The FRN can be obtained electronically through the FCC webpage at https://svartifoss2.fcc.gov/cores/CoresHome.html or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC’s web site at http://www.fcc.gov/formpage.html, by calling the FCC’s Forms Distribution Center 800-418-FORM (3676), or from Right Fax by dialing (202) 418-0177.

If you owe a past debt to the Federal Government, any information you provide may also be disclosed to the Department of Treasury Financial Management Service, other federal agencies and/or your employer to offset your salary, IRS tax refund or other payments to collect that debt. The FCC may also provide this information to these agencies through the matching of computer records when authorized. In addition, all information provided in this form will be available for public inspection. If information requested on the form is not provided, processing of the application may be delayed or the application may be returned without action.

This notice is required by the Privacy Act of 1974, Public Law 93-579, December 31, 1974, 5 U.S.C. Section 552a(e)(3) and the Paperwork Reduction Act of 1995, Public Law 104-13, October 1, 1995, 44 U.S.C. 3507.

FCC 405 – INSTRUCTIONS

JULY 2005 – PAGE 1

INSTRUCTIONS FOR COMPLETING FCC FORM 405

In general, all applications for renewal of experimental radio service applications must be filed electronically. The instructions that follow are for filing FCC Form 405 applications when a wavier of the applicable fee is requested. All paper applications must be accompanied by an attachment specifying the reasons for such a waiver. Fee information and mailing requirements for electronic filing are provided on-line when the application is submitted.

FCC Form 405 is used by the Experimental Radio Service to apply for renewal of radio station licenses. Section 307(c) of the Communications Act limits the term of a radio license and requires that applications be submitted for renewal. FCC Form 405 is required by 47 CFR Part 5.

A. Complete the application and submit the completed FCC Form 405 to the Federal Communications Commission at the appropriate address noted below. The current fee amount and Payment Type Code (required for feeable applications) for Part 5 can be found in the OET Fee Filing Guide. The OET Fee Filing Guide can be downloaded from http://www.fcc.gov/fees/appfees.html, or obtained by calling the FCC's Forms Distribution Center at (800) 418-FORM (3676) or from Right Fax by dialing (202) 418-0177. Fee Exemption: Eligibility for filing as a fee exempt applicant may be determined by referencing 47 CFR 1.1114.

2. Name of applicant (Item 1) and Location (Item 3d) must be identical with that shown on the current authorization.

Applicable Rules and Regulations

Applicants should obtain the relevant parts of the FCC’s rules in 47 CFR. Copies of 47 CFR may be purchased from the Superintendent of Documents; Government Printing Office; Washington, DC 20402; (202) 512-1800. Refer also to the Government Printing Office’s website at http://www.access.gpo.gov. Some FCC rules require applicants to attach one or more exhibits to an application in addition to the information requested in the application form.

FCC Form 159, “Remittance Advice”, and FCC Form 159-C, (Continuation Sheet) is a multi-purpose form that must accompany any payment to the Federal Communications Commission (e.g., Regulatory Fees, Processing Fees, Auctions, Fines, Forfeitures, Freedom of Information Act (FOIA) Billings, or any other debt due to the FCC). The information on FCC Form 159 is collected to ensure credit for full payment, to ensure you receive any refunds due, to service public inquiries, and to comply with the Debt Collection Improvement Act of 1996. (If filing electronically, this form will be provided on-line.)

(a) BY MAIL, SEND YOUR FEEABLE RENEWAL APPLICATION PACKAGE WITH PAYMENT & FCC FORM 159 TO:

Federal Communications Commission

Experimental Radio Service

P. O. Box 979095

St. Louis, MO 63197-9000

*(b) BY HAND-DELIVERY OR COURIER SERVICE:

Federal Communications Commission

US Bank,

Government Lockbox

1005 Convention Plaza

St. Louis, MO 63197-9000

* Applications hand delivered or sent by courier should be placed in an inner envelope with address (a) and then submitted to address (b).

(c) BY MAIL, HAND-DELIVERY OR COURIER SERVICE, SEND YOUR NON-FEEABLE RENEWAL APPLICATION PACKAGE TO:

Federal Communications Commission

Office of Engineering and Technology

Experimental Licensing Branch

445 12th Street, SW

Washington, DC 20554

FCC 405 – INSTRUCTIONS

JULY 2005 – PAGE 2

FCC 405 FEDERAL COMMUNICATIONS COMMISSION Approved by OMB

3060-0093

APPLICATION FOR RENEWAL OF RADIO STATION LICENSE

FOR EXPERIMENTAL RADIO SERVICE (47 CFR Part 5)

			File Number (FCC USE ONLY)
1. Name Of Applicant (must be identical with that shown on current authorization)
Mailing Street Address Or P. O. Box, City, State and ZIP Code of Applicant
E-Mail address		(Area Code) Telephone Number
Call Sign or Other FCC Identifier	FCC Registration Number (FRN)	Identify Rule/subpart under which filing is made

2. Application is for renewal of license in exact conformity with the existing license as specified below:

(a) File Number	(b) Date Issued		(c) Call Sign		(d) Location
(e) Nature of Service		(f) Class of Station		(g) Expiration Date
3. Note any changes which have been made since the last application covering this station was filed (i.e., discontinuance of use of a frequency, type of emission, transmitter, etc.)
Applicant represents that there has been no change in applicant’s organization and no transfer of control or changes in the applicant’s relation to the station or financial responsibility; that the applicant’s most recent application or report embodying this information, as identified below, is to be considered as part of this application, and the truth statement therein contained is hereby affirmed. File Number: Date:
5. CERTIFICATION --Neither the applicant nor any other party to the application is subject to a denial of Federal benefits that includes FCC benefits pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. Section 862, because of a conviction for possession or distribution of a controlled substance. --The applicant hereby waives any claim to the use of any particular frequency or electromagnetic spectrum as against the regulatory power of the United States because of the previous use of same, whether by license or otherwise, and requests authorization in accordance with this application. (See Section 304 of the Communications Act of 1934, as amended.) --The applicant acknowledges that all statements made in the application and attached exhibits are considered material representations; and that all the exhibits are a material part hereof and are incorporated herein as if set out in full in this application, undersigned certifies that all statements in this application are true, complete and correct to the best of his/her knowledge and belief and are made in good faith. --Applicant certifies that construction of the station would NOT be an action which is likely to have a significant environmental effect. See the Commission’s Rules, 47 CFR 1.1301-1.1319.
WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18, § 1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, § 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, § 503).
Type or Print Name of Person Signing			Title of Person Signing
Signature			Date

Designate appropriate classification

Individual Member of Officer & Member of Authorized Rep. Official of

Partnership Applicant’s Association of Corporation Government

Entity

FCC 405 JULY 2005