Fillable Ncvec Quick-Form 605 Application - Amateur Operator/primary Station License printable pdf download

NCVEC QUICK-FORM 605 APPLICATION

AMATEUR OPERATOR/PRIMARY STATION LICENSE

SECTION 1 - TO BE COMPLETED BY APPLICANT

SUFFIX (Jr., Sr.)

FIRST NAME

PRINT LAST NAME

M.I.

STATION CALL SIGN (IF ANY)

FEDERAL REGISTRATION NUMBER (FRN) - IF NONE,

MAILING ADDRESS (Number and Street or P.O. Box)

THEN SOCIAL SECURITY NUMBER (SSN)

STATE CODE ZIP CODE (5 or 9 Numbers)

DAYTIME TELEPHONE NUMBER (Include Area Code)

CITY

E-MAIL ADDRESS (MANDATORY)

Basic Qualification Question:

Has the Applicant or any party to this application, or any party directly or indirectly controlling the Applicant, ever been convicted of a

felony by any state or federal court?

YES

If “YES”, see “FCC BASIC QUALIFICATION QUESTION INSTRUCTIONS AND PROCEDURES” on the back of this form.

I HEREBY APPLY FOR (Make an X in the appropriate box(es)):

CHANGE my mailing address to above address

EXAMINATION for a new license grant

CHANGE my station call sign systematically

EXAMINATION for upgrade of my license class

Applicant’s Initials: To Confirm

RENEWAL of my license grant

CHANGE my name on my license to my new name

Former Name:

Exp. Date:

(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 fai th;

•

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.

S ignature of Applicant:

Date Signed

SECTION 2 - TO BE COMPLETED BY ALL ADMINISTERING VEs

Applicant is qualified for operator license class:

DATE OF EXAMINATION SESSION

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

DO NOT SEND THIS FORM TO FCC – THIS IS NOT AN FCC FORM.

NCVEC FORM 605 - September 2017

FOR VE/VEC USE ONLY - Page 1

IF THIS FORM IS SENT TO FCC, FCC WILL RETURN IT TO YOU WITHOUT ACTION.

Ncvec Quick-Form 605 Application - Amateur Operator/primary Station License

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