ROA-NEW Form for OMB June 2023 (6-22-23)(3060-0357)

DRAFT

ROA-NEW Form

FCC [[#]] ROA-NEW

FCC Application for Designation as a Recognized Operating Agency (ROA) Office of International Affairs

Not Yet Approved By OMB 3060-0357 See instructions for public burden estimate

Applicant Information

1. Applicant Information

• FRN

• Applicant/Licensee Legal Entity Type (Select One)

  • Individual: (check box)

  • Unincorporated Association: (check box)

  • Government Entity: (check box)

  • Corporation: (check box)

  • Limited Liability Company: (check box)

  • General Partnership : (check box)

  • Limited Partnership: (check box)

  • Limited Liability Partnership: (check box)

  • Consortium: (check box)

  • Other: (check box and Fill-in box)

• Name and title; Doing Business As (DBA), address; phone; fax; email; attention to (imported from CORES during authentication).

2. Contact Information

Check here if same as Applicant: (Check Box)

• (If different from the Applicant): Name and title; Doing Business As (DBA), company name; relationship, address; phone; fax; email; (individual fields editable)

Application Information

3. Application Description. (editable a fill in box for Applicant to supply a short description of action requested)

Ownership Information

4. Is the Applicant a corporate Applicant or similar business entity organized under the laws of a Government, State, or Territory?

• Yes (check box) [If yes, go to 4a. If no, continue to 5]

• No (check box)

4a. Select the Government, State, or Territory under the laws of which the Applicant is organized. [Drop-down menu for country. If United States is selected, a separate drop-down with the states and territories.]

5. Provide, in the fields below, the name, address, citizenship, and principal business of the Applicant’s 10% percent or greater direct and indirect shareholders, or other equity holders.

a) Name Entity/Individual	b) Percentage owned	c) Name of entity in which ownership is held	d) Citizenship of Individual/Country of Incorporation	e) Address	f) Principal Business
Fill-in box	Fill-in box	Fill-in box	Drop-down menu of countries.	Fill-in box	Fill-in box

6. The Applicant has attached a statement of the ownership of a non-corporate Applicant, or the ownership of the stock of a corporate Applicant, including an indication whether the Applicant or its stock is owned directly or indirectly by an alien.

• Yes (check box)

• No (check box)

Requirements pursuant to 47 CFR § 63.701

7. The Applicant has attached a copy of the Applicant’s articles of incorporation (or its equivalent) and a copy of its corporate bylaws.

• Yes (check box)

• Not Applicable (Not a corporate Applicant) (check box)

8. Applicant Description. Check all that apply.

• A carrier subject to section 214 of the Communications Act of 1934, as amended (check box)

• An operator of broadcast or other radio facilities, licensed under Title III of the Communications Act of 1934, as amended, capable of causing harmful interference with the radio transmissions of other countries (check box)

• A non-carrier provider of services classed as “enhanced” under section 64.702(a) of the Commission’s rules (check box)

9. The Applicant has attached a statement indicating that the services for which designation as a ROA is sought will be extended to a point outside the United States or are capable of causing harmful interference of other radio transmission and a statement of the nature of the services to be provided.

• (check box)

10. The Applicant has attached a statement setting forth the points between which the services are to be provided.

• (check box)

11. The Applicant has attached a statement as to whether covered services are provided by facilities owned by the Applicant, by facilities leased from another entity, or other arrangement and a description of the arrangement.

• (check box)

12. The Applicant certifies that it is aware that it is bound by all laws and obligations of the United States, including that it is obligated under Article 6 of the International Telecommunication Union (ITU) Constitution to obey the mandatory provisions thereof, and all regulations promulgated thereunder. The Applicant pledges that it will engage in no conduct or operations that contravene such mandatory provisions and that it will otherwise obey the Convention and regulations in all respects. The Applicant is aware that failure to comply will result in an order from the Federal Communications Commission to cease and desist from future violations of an ITU regulation and may result in revocation of its recognized operating agency status by the United States Department of State.

• (check box)

Application Fees

13. Will a fee be paid? 

• Yes (check box) 

• No (check box) 

 

13a. If yes, select the appropriate fee code for the application. 

[[Add drop Down box to select fee code]] 

13b. If no, indicate reason for fee exemption. 

• Governmental Entity (check box) 

• Noncommercial educational license (check box) 

• Other (Explain) [Fill-in box for explanation] 

 

Waivers

14. Does the Applicant request a waiver(s) of the Commission’s rules?  

• Yes (check box) 

• No (check box) 

 

14a.  If yes, Identify the rule section(s) for which a waiver is sought below and attach the request with a supporting narrative and documentation. 

[Fill-in box] 

15. The Applicant has uploaded a statement explaining the waiver request and identifying the rule number(s) involved, along with other material information.

• Yes (check box) 

• N/A (check box) 

Attachments/Confidential Treatment of Attachments

16. Is the Applicant requesting confidential treatment of an attachment(s) under section 0.459 of the Commission’s rules?

1. Yes (check box) The Applicant must upload a supporting statement for the “confidential treatment request(s)” identifying the applicable rule(s) and providing other supporting materials or information. The Applicant must also upload both the Redacted Public version and the Non-Redacted Confidential version of the attachment(s) in the Attachments section below.

2. No (check box)

Attachment No.	Description of Attachment	Confidential Treatment Requested
Attachment 1	[Fill in box]	[check box]
Attachment 2 (Public Version of Confidential Treatment Request and Supporting Statement)	[Fill in box]
Attachment 2(a) (Public Redacted Version)	[Fill in box]
Attachment 2(b) (Confidential Non-Redacted Version)	[Fill in box]

Certification Statements

17. In submitting this form:

• The Applicant certifies that it has submitted all necessary statements and exhibits required by 47 CFR § 63.701.

• The Applicant certifies that neither it nor any other party to the application is subject to a denial of Federal benefits, including FCC benefits pursuant to section 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.  See 47 CFR § 1.2002(b) for the meaning of "party to the application" for these purposes. (This certification does not apply to applications filed in services exempted under § 1.2002(c) of the rules, or to Federal, State or local governmental entities or subdivisions thereof. See 47 CFR § 1.2002(c).)

• Applicant certifies that all of its statements made in this Application and in the attachments or documents incorporated by reference are material, are part of this Application, and are true, complete, correct, and made in good faith.

[check box]

18. Party Authorized to Sign

First Name:	MI:	Last Name:		Suffix:
Title:
Signature:			Date:
FAILURE TO SIGN THIS APPLICATION MAY RESULT IN DISMISSAL OF THE APPLICATION AND FORFEITURE OF ANY FEES PAID
WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18 Section 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, Section 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503)

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