Licensee Notification Form

1/25/22, 4:05 PM

Licensee Notification Form

Licensee Notification Form
This form is intended for the notification of events outlined in § 960.8(e) Standard license
conditions for all tiers.
The respondent's email (null) was recorded on submission of this form.
* Required

1.

Email *

2.

Name of Licensee *

3.

Name of Licensed System *

4.

First Name *

5.

Last Name *

6.

E-mail *

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Licensee Notification Form

7.

Phone number *

8.

Preferred contact method *
Check all that apply.
Phone
Email

Please describe which event you would like to notify CRSRA of *

9.

Mark only one oval.
The launch and deployment of each system component, to include confirmation that
the component matches the orbital parameters and data collection characteristics of the
system
Skip to question 10
Disposal of an on-orbit component of the system
The detection of an anomaly
Financial insolvency

Skip to question 18

Skip to question 14

Skip to question 16

The launch or deployment of each system component, to include confirmation that
the component matches the orbital parameters and data collection characteristics
of the system

10.

Name of component launched or deployed *

11.

Date of launch or deployment of component *

Example: January 7, 2019

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12.

Licensee Notification Form

Is the component on orbit? *
Mark only one oval.
Yes
No
Other:

13.

Do the orbital parameters and data collection characteristics match the licensed
capabilities? *
Mark only one oval.
Yes
No. If no, you must submit a license modification request with the updated
characteristics.

Detection
of an
anomaly

14.

An unexpected event or abnormal characteristic affecting the operations of a system that
could indicate a significant technical malfunction or security threat. Anomalies include
any significant deviation from the orbit and data collection characteristics of the system.

Date of anomaly *

Example: January 7, 2019

15.

Description of anomaly(ies) *

Financial insolvency or dissolution
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16.

Licensee Notification Form

Date of insolvency or dissolution *

Example: January 7, 2019

17.

Description of insolvency or dissolution *

Please provide details on the disposal of an on-orbit component of the system.

18.

Name of component *

19.

Date of disposal *

Example: January 7, 2019

20.

Description of disposal *

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Licensee Notification Form

 Forms

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