Form Fcc 383 Draft - Digital Channel Election For Television Broadcast Station: First Round Conflict Decision Page 8

DRAFT

SECTION III

I certify that the statements in this form are true, complete, and correct to the best of my knowledge and belief, and are made in

good faith. I acknowledge that all certifications and attached Exhibits are considered material representations. I hereby waive any

claim to the use of any particular frequency as against the regulatory power of the United States because of the previous use of the

same, whether by license or otherwise, and request an authorization in accordance with this election form. (See Section 304 of the

Communications Act of 1934, as amended.)

Typed or Printed Name of Person Signing

Typed or Printed Title of Person Signing

Signature

Date

WILLFUL FALSE STATEMENTS 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).

FCC Form 383

(date)

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