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

Non-Public/For Internal Use Only

ROA-WAV Form

FCC [[#]] ROA-WAV

Waiver Application for Recognized Operating Agency (ROA) International Bureau

Not Yet Approved by OMB 3060-[xxx] 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. Waiver Description/Action Requested: (editable a fill in box for Applicant to supply a short description of action requested)

Application Fees

4. Will a fee be paid? 

• Yes (check box) 

• No (check box) 

 

4a.  If yes, select the appropriate fee code for the application. 

[[Down box to select fee code]]

4b. If no, indicate reason for fee exemption. 

• Governmental Entity (check box) 

• Noncommercial educational license (check box) 

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

Attachment(s)

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

(check box)

Attachments/Confidential Treatment of Attachments

6. 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

7. In submitting this form,

• The Applicant certifies that it has submitted all statements and exhibits to support this waiver request.

• 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 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]

8. 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)

[Back End]

• We use all tabs currently on the back end of IBFS.

• Essentially this should look the same on the back-end as the ROA/NEW with most of the fields left blank with the ability to bring the info from the related ROA form if there is one.

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