Ncvec 605 Form

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NCVEC QUICK-FORM 605 APPLICATION FOR
AMATEUR OPERATOR/PRIMARY STATION LICENSE
SECTION 1 - TO BE COMPLETED BY APPLICANT
PRINT LAST NAME
SUFFIX (Jr., Sr.)
FIRST NAME
INITIAL
STATION CALL SIGN (IF ANY)
MAILING ADDRESS (Number and Street or P.O. Box)
SOCIAL SECURITY NUMBER (SSN) or (FRN) FCC FEDERAL
REGISTRATION NUMBER
CITY
STATE CODE
ZIP CODE (5 or 9 Numbers)
E-MAIL ADDRESS (OPTIONAL)
DAYTIME TELEPHONE NUMBER (Include Area Code) OPTIONAL
FAX NUMBER (Include Area Code) OPTIONAL
ENTITY NAME (IF CLUB, MILITARY RECREATION, RACES)
Type of
Amateur
Military
RACES
CLUB, MILITARY RECREATION, OR RACES CALL SIGN
Applicant:
Individual
Club
Recreation
(Modify Only)
SIGNATURE OF RESPONSIBLE CLUB OFFICIAL (not trustee)
I HEREBY APPLY FOR (Make an X in the appropriate box(es))
EXAMINATION
CHANGE
for a new license grant
my mailing address to above address
EXAMINATION
CHANGE
for upgrade of my license class
my station call sign systematically
CHANGE
my name on my license to my new name
Applicant’s Initials: __________________
RENEWAL
Former Name: _______________________________
of my license grant.
(Last name) (Suffix)
(First name)
(MI)
PURPOSE OF OTHER APPLICATION
PENDING FILE NUMBER (FOR VEC USE ONLY)
Do you have another license application on file
with the FCC which has not been acted upon?
I certify that:
I waive any claim to the use of any particular frequency regardless of prior use by license or otherwise;
All statements and attachments are true, complete and correct to the best of my knowledge and belief and are made in good faith;
I am not a representative of a foreign government;
I am not subject to a denial of Federal benefits pursuant to Section 5301of the Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862;
The construction of my station will NOT be an action which is likely to have a significant environmental effect (See 47 CFR Sections 1.1301-1.1319
and Section 97.13(a));
I have read and WILL COMPLY with Section 97.13(c) of the Commission’s Rules regarding RADIOFREQUENCY (RF) RADIATION SAFETY and
the amateur service section of OST/OET Bulletin Number 65.
Signature of applicant: Must match applicant’s name above.
Clubs: 2 different individuals must sign.
X
______________________________________________________________
Date Signed: ___________________
SECTION 2 - TO BE COMPLETED BY ALL ADMINISTERING VEs
DATE OF EXAMINATION SESSION
Applicant is qualified for operator license class:
NO NEW LICENSE OR UPGRADE WAS EARNED
EXAMINATION SESSION LOCATION
TECHNICIAN
Element 2
VEC ORGANIZATION
GENERAL
Elements 2 and 3
VEC RECEIPT DATE
AMATEUR EXTRA
Elements 2, 3 and 4
I CERTIFY THAT I HAVE COMPLIED WITH THE ADMINISTERING VE REQUIRMENTS IN PART 97 OF THE
COMMISSION’S RULES AND WITH THE INSTRUCTIONS PROVIDED BY THE COORDINATING VEC AND THE FCC.
1st VEs NAME (Print First, MI, Last, Suffix)
VEs STATION CALL SIGN
VEs SIGNATURE (Must match name)
DATE SIGNED
2nd VEs NAME (Print First, MI, Last, Suffix)
VEs STATION CALL SIGN
VEs SIGNATURE (Must match name)
DATE SIGNED
3rd VEs NAME (Print First, MI, Last, Suffix)
VEs STATION CALL SIGN
VEs SIGNATURE (Must match name)
DATE SIGNED
NCVEC FORM 605 - June 2015
DO NOT SEND THIS FORM TO FCC – THIS IS NOT AN FCC FORM.
FOR VE/VEC USE ONLY - Page 1
IF THIS FORM IS SENT TO FCC, FCC WILL RETURN IT TO YOU WITHOUT ACTION.

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