RTL-WAV Form to OMD March 19 2024

DRAFT – March 2024

FCC [[#]] RTL-WAV]

Waiver Application for International Route List (International Service Providers to Identify Direct Termination Arrangements With A Foreign Carrier)

Not Yet Approved by OMB No. 3060-0686 Estimated time per response: 2 hours Edition date: [XXXX 2024]

[link to instructions]

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 then (Fill-in box)

• Name and title; Doing Business As (DBA), address; phone; fax; email; attention to (imported from CORES during authentication) (individual fields should not be editable here, but Applicant should be able to change FRN using CORES).

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 should be editable on the form screen)

Application Information

3. Brief Application Description. (editable field for Applicant to supply a short description)

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]]

Attachments/Confidential Treatment of Attachments

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

• Yes (check box)

• No (check box)

[If the answer to Q4 is “Yes”] 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.

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]	[check box]

Attachment(s)

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

(check 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 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.

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).

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