FCC Form 2100, Application for Media Bureau Audio and Video Service Authorization, Schedule E (Former FCC Form 301-CA); 47 CFR Section 74.793(d)

FCC Form2100 application for Media Bureau Video Service Authorization, Schedule E OMB CONTROL NUMBER: 3060-0932 Edition Date: October 2016

Approved by OMB

Alien Ownership screen

1) Is the applicant a foreign government or the representative of any foreign government as specified in Section 310(a) of the Communications Act?

2) Is the applicant an alien or the representative of an alien? (Section 310(b)(1))

3) Is the applicant a corporation, or non-corporate entity, that is organized under the laws of any foreign government? (Section 310(b)(2))

4) Is the applicant an entity of which more than one-fifth of the capital stock, or other equity or voting interest, is owned of record or voted by aliens or their representatives or by a foreign government or representative thereof or by any entity organized under the laws of a foreign country? (Section 310(b)(3))

5) Is the applicant directly or indirectly controlled by any other entity of which more than one-fourth of the capital stock, or other equity or voting interest, is owned of record or voted by aliens, their representatives, or by a foreign government or representative thereof, or by any entity organized under the laws of a foreign country? (Section 310(b)(4))

6) Has the applicant received a declaratory ruling(s) under Section 310(b)(4) of the Communications Act?

6a) Enter the citation of the applicable declaratory ruling by DA/FCC number, FCC Record citation, release date, or any other identifying information.

7) Has there been any change in the applicant's foreign ownership since issuance of the declaratory ruling(s) cited in response to Question 6?

8) Does the applicant certify that it is in compliance with the terms and conditions of the foreign ownership declaratory ruling(s) cited in response to Question 6?

9) In connection with this application, is the applicant filing a foreign ownership Petition for Declaratory Ruling pursuant to Section 310(b)(4) of the Communications Act

Certification

General Certification

Statements

The 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 authorization or

otherwise, and requests an Authorization in accordance with

this application (See Section 304 of the Communications Act

of 1934, as amended.).

The Applicant certifies that neither the Applicant nor any

other party to the application is subject to a denial of Federal

benefits pursuant to §5301 of the Anti-Drug Abuse Act of

1988, 21 U.S.C. §862, because of a conviction for

possession or distribution of a controlled substance. This

certification does not apply to applications filed in services

exempted under §1.2002(c) of the rules, 47 CFR . See

§1.2002(b) of the rules, 47 CFR §1.2002(b), for the definition

of "party to the application" as used in this certification

§1.2002(c). The Applicant certifies that all statements made

in this application and in the exhibits, attachments, or

documents incorporated by reference are material, are part

of this application, and are true, complete, correct, and made

in good faith.

Authorized Party to Sign FAILURE TO SIGN THIS APPLICATION MAY RESULT IN

DISMISSAL OF THE APPLICATION AND FORFEITURE

OF ANY FEES PAID

Upon grant of this application, the Authorization Holder may

be subject to certain construction or coverage requirements.

Failure to meet the construction or coverage requirements

will result in automatic cancellation of the Authorization.

Consult appropriate FCC regulations to determine the

construction or coverage requirements that apply to the type

of Authorization requested in this application.

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

AUTHORIZATION (U.S. Code, Title 47, §312(a)(1)),

AND/OR FORFEITURE (U.S. Code, Title 47, §503).

I certify that this application includes all required and relevant

attachments.

I declare, under penalty of perjury, that I am an authorized

representative of the above-named applicant for the

Authorization(s) specified above.

FCC NOTICE TO INDIVIDUALS REQUIRED BY THE

PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of

information will take 225 – 6 hours. Our estimate includes the time to

read the instructions, look through existing records, gather and

maintain the required data, and actually complete and review the

form or response. If you have any comments on this burden

estimate, or on how we can improve the collection and reduce

the burden it causes you, please e-mail them to [email protected] or

send them to the Federal Communications Commission, AMDPERM,

Paperwork Reduction Project (3060-0932),

Washington, DC 20554. Please DO NOT SEND

COMPLETED APPLICATIONS 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 of if we fail to

provide you with this notice. This collection has been assigned

an OMB control number of 3060-0932.

THE FOREGOING NOTICE IS REQUIRED BY THE

PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13,

OCTOBER 1, 1995, 44 U.S.C. Section 3507.