Form 161 - Cores Update And Change Form printable pdf download

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FEDERAL COMMUNICATIONS COMMISSION

BEFORE PROCEEDING

3060-0918

Commission Registration System (CORES)

FORM 161 – CORES Update and Change Form

FCC USE ONLY

September 2005

1. FCC Registration Number (FRN): ___________________________

2. Entity Type: ____ ____

3. Business Entity Type (if applicable): ____ ____

4. Business Entity Name: ___________________________________________________________________________________

4a. Salutation: ________ First Name: ______________________________________________________ Middle Initial: _____

Last Name: ___________________________________________________________________________ Suffix: ___________

5. Doing Business or Trading As: ____________________________________________________________________________

6. Contact Representative Organization/Company: _______________________________________________________________

7. Contact Representative Position/Title: _______________________________________________________________________

8. Contact Representative First Name: __________________________________________________ Middle Initial: _________

Contact Representative Last Name: ___________________________________________________________________________

9. Address: ______________________________________________________________________________________________

10. Address 2: ____________________________________________________________________________________________

11. Address 3: ____________________________________________________________________________________________

12. Address 4: ____________________________________________________________________________________________

13. City: ________________________________________ 14. State: ___ ___ 15. Zip Code: ________________ - __________

16. Country: _____________________________________________________________________________________________

17. Contact Representative Phone Number: ______________________________ 18. FAX: ______________________________

19. Contact Representative E-Mail: ___________________________________________________________________________

20. Personal Security Question (select only one):

20a. Custom Personal Security Question (if applicable): _______________

___ Mother’s Maiden Name

___ City of Birth

_________________________________________________________

___ Favorite Pet’s Name

___ Corporate Internal Employee ID

_________________________________________________________

___ Custom Personal Security Question

21. Personal Security Question Answer: _______________________________________________________________________

22. Certification Statement: I, ___________________________, certify under penalty of perjury that the foregoing and supporting

information is true and correct to the best of my knowledge, information, and belief.

Signature: _________________________________________________________

Date: _______________________________

Form 161 - Cores Update And Change Form