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FCC 601 Worksheet

Applicant Information

Applicant Taxpayer Id #:

Must have this information to process the application

Applicant Name:

First:
Last:
MI:
Person who will be signing the application

Title:

Company Name:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

E-mail Address:

Organization Type

Select

Describe the applicants
type of business:

Dealer Information

Contact Person:

Company:

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail Address:

Licensing Data

Please describe your need for this application:

Will the new Frequencies be:

Is this a new System?

Yes:

No:

If No, what is your current call sign?

If we are modifying the License,
what are we doing?

Repeater & Mobiles:

Number of frequencies requested:

Total Number of Mobiles & Portables:

Output Power: ERP:

Repeater or Base:

Output Power: ERP:

Frequency Band (MHz)

If you are requesting specific frequencies please indicate here:

Is there a telephone Interconnect?

Yes:

No:

Portables and Mobile Applicants May Stop here.

Base & Repeater Transmitter Site Data

Station Address/Geographic Location:

City:

County:

State:

Latitude:

Longitude:

Datum used to plot coordinates:

Ground Elevation:

Feet

Height of Structure:

Feet

Overall Height to tip:

Feet (Antenna Height)

Structure Type:

If Other:

How is the antenna mounted to the structure, please describe:

Is this a new or existing site?

If existing, call sign of existing user on this site:

Tower owners name:

Telephone #:

Antenna Structure Registration

Do you know of an existing FAA Notification on the site?

Yes:

No:

If yes #