Application To Participate In An Fcc Auction Fcc 175 printable pdf download

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Federal Communications Commission

Special Use

3060-0600

Washington, D. C. 20554

FCC Use

Application to Participate in an FCC Auction

Only

(Read Instructions Before Completing)

1. Applicant

8. Applicant Classification:

Individual

Joint Venture

Partnership

Trust

Corporation

Consortium

LLC

Govt. Entity

Association

2. Mail Address (No P.O. Boxes)

9. Applicant Status:

10. Bidding Credit

Eligibility

Rural telephone company

___% Bidding Credit

5. ZIP Code

3. City

4. State

Percentage

Minority owned business

Small Business

Woman owned business

6. Auction Number

7. Taxpayer Identification No.

Very Small Business

Noncommercial Educational

None of the above

New Entrant

11. Entrepreneur

12. Licenses or construction permits for which you want to bid. If bidding for Wireless licenses, use

Eligibility (if appropriate)

Schedule A. If bidding for Broadcast construction permits, use Schedule B.

Total assets and

gross revenues do

13.

Check here if exhibits are attached. Indicate number of supplemental exhibits attached:

not exceed the

14. Person(s) authorized to make or withdraw a bid (Identify up to three.)

maximum dollar

amounts

(a)

(b)

(c)

Certification: I certify the following:

(1)

that the applicant is legally, technically, financially and otherwise qualified pursuant to 308(b) of the Communications Act and the

Commission's Rules and is in compliance with the foreign ownership provisions contained in Section 310 of the Communications

Act.

that the applicant is the real party in interest in this application and that there are no agreements or understandings other than those

(2)

specified in this application (see Instructions for certification), which provide that someone other than the applicant shall have an

interest in the license.

(3)

that the applicant is aware that, if upon Commission inspection, this application is shown to be defective, the application may be

dismissed without further consideration, and certain fees forfeited. Other penalties may also apply.

except as explicitly provided in the Commission's Rules, that the applicant has not entered into and will not enter into any explicit or

(4)

implicit agreements or understandings of any kind with parties not identified in this application regarding the amount to be bid,

bidding strategies or the particular license on which the applicant or other parties will or will not bid.

(5)

that the applicant, or any party to this application, is not subject to a denial of federal benefits pursuant to Section 5301 of the

Anti-Drug Abuse Act of 1988.

that if a bidding credit eligibility is claimed in block 10, the applicant is eligible for any special provisions set forth in the

(6)

Commission's Rules applicable to this auction and consents to audits, as set forth in the Commission's Rules, to verify such status.

(7)

that the applicant is and will, during the pendency of its application(s), remain in compliance with any service specific qualifications

applicable to the licenses on which the applicant intends to bid including, but not limited to, financial qualifications.

(8)

that the applicant is not in default on any payment for Commission licenses and that it is not delinquent on any non-tax debt owed to

any federal agency.

I declare, under penalties of perjury, that I am an authorized representative of the above-named applicant for the license(s)

and/or construction permits specified above, that I have read the instructions and the foregoing certification and all matters and

things stated in this application, its schedules and attachments, including exhibits, are true and correct.

Telephone No.

15. Name of Person Certifying

16. Contact Person

City

State

ZIP Code

Contact Person Address (No P.O. Boxes)

Date

Title of Person Certifying

E-mail Address

FAX No.

Willful false statements made on this form are punishable by fine and/or imprisonment (U.S. Code, Title 18, Section 1001), and/or

FCC 175

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,

October 2000

Section 503).

Application To Participate In An Fcc Auction Fcc 175

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