Information for FCC radio license application (Click Here for printer friendly .pdf form) PLEASE PRINT ALL INFORMATION CLEARLY!  Fax the completed form to HF Radio On Board at 510-291-3167 There is an $125 form preparation fee in addition to fees due the FCC, payable in advance. IF YOU HAVE AN EXISTING UNEXPIRED FCC LICENSE FOR YOUR VESSEL IN YOUR NAME, PLEASE PROVIDE A COPY OF THAT LICENSE. Please provide a password you would like to use, or we will use the boat name by default. All applicants: Do you have a FRN (Federal Registration Number)? Y/N FRN:________________________________________ Password:____________________________________ Individual Applicant First Name:                                       Middle Initial:    Last Name:                                        Suffix (Jr., Sr., II, etc): Social Security Number/TIN:                              Date of birth:                                          (mm/dd/yyyy) Do you possess a FCC Restricted Radiotelephone Operators Permit? Y/N Or applicant is (circle one) Corporation  Unincorporated Association  LLC  Trust  Partnership  Government Entity  Joint Venture  Consortium    Entity Name:                                                                  TIN: Attention:   All applicants P.O. Box: Street Address: City:                                    State:      Zip:                      Country: Telephone: Fax: Email: Are you eligible for employment in the United States? Y/N Ship Information Circle one:  Pleasure    Merchant     Rescue      Official Service Ship Type of vessel (i.e.: Motorboat, Sailing Ship, Sloop, Yacht): Name of vessel:                          Length: Coast Guard Document Number or State Registration Number (i.e.: CF number): MMSI Number (if assigned):                          Assigned by: Emergency Contact Information Primary Contact Name: Address: City:                                  State/Prov:         Zip/Postal Code: Country: Telephone: Fax: Email: Alternate Contact Name: Address: City:                                  State/Prov:         Zip/Postal Code: Country: Telephone: Fax: Email: Radio Information EPIRB Identification Code (15 digit code provided by manufacturer) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Radio Installation (check all that apply) Inmarsat _ A _ B _ C _M _ Mini-M Radio _ VHF _ SSB  With DSC  _VHF _SSB EPIRB _ 406 MHz _ 121.5 MHz Search and Rescue Transponder _ Maximum Vessel Capacity____ (persons – passengers and crew) Number of Liferafts___  Lifeboats___ Credit Card for fee payment (must be card in applicants name) Name exactly as it appears on the card:_____________________________________ Visa/Mastercard/Amex Account Number:________________________                                                     Expiration Date (mm/yyyy)_______  Security Code:__________ The security code is the last 3 digits of the number on the signature stripe on the rear of Visa/MasterCard or the 4 digits printed on the front of American Express right above the end of the embossed card number. Signature for Card:_________________________________________ Certification Statement for Restricted Radio Telephone Operators Permit Only 1 I am legally eligible for employment in the United States. (All U.S. citizens are considered, for the purposes of this application, to be legally eligible for employment in the U.S.)   2 I can keep at least a rough written log.   3 I can speak and hear.   4 I am familiar with the provisions of the applicable laws, treaties, rules, and regulations governing the radio station which will be operated.     5 I need this permit because of intent to engage in international voyages or flights, international communications, or intent to comply with the requirements of the Vessel Bridge-to-Bridge Radiotelephone Act.   Signature:_______________________________________________   General Certification Statements     1 The applicant/licensee waives any claim to the use of any particular frequency or of the electromagnetic spectrum as against the regulatory power of the United States because of the previous use of the same, whether by license or otherwise, and requests an authorization in accordance with this application.   2 The applicant/licensee certifies that all statements made in this application and in the exhibits, attachments, or documents incorporated by reference are material, are part of this application, and are true, complete, correct, and made in good faith.   3 Neither the applicant/licensee nor any member thereof is a foreign government or a representative thereof.   4 The applicant/licensee certifies that neither the applicant/licensee nor any other party to the application is subject to a denial of Federal 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. This certification does not apply to applications filed in services exempted under Section 1.2002© of the rules, 47 CFR § 1.2002©. See §1.2002(b) of the rules, 47 CFR § 1.2002(b), for the definition of "party to the application" as used in this certification.     Certification Statements for Ship Applicants/Licensees (Including Ship Exemptions)     1 Applicant/Licensee certifies that they are the owner or operator of the vessel, a subsidiary communications corporation of the owner or operator of the vessel, a state or local government subdivision, or an agency of the US Government subject to Section 301 of the Communications Act.   2 This application is filed with the understanding that any action by the Commission thereon shall be limited to the voyage(s) described herein, and that apart from the provisions of the specific law from which the applicant/licensee requests an exemption, the vessel is in full compliance with all applicable statues, international agreements and regulations.     Signature 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 OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18, §1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, §312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, §503).   Name of Party Authorized to Sign   First Name:                                    MI       Last   Title   Signature:_______________________________________________

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