Application Form For Class A Television Broadcast Station Page 13

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Part C: PREPARER'S CERTIFICATION
I certify that I have prepared Section III (Engineering Data) on behalf of the applicant, and that after such preparation, I have
Name
Relationship to Applicant (e.g., Consulting Engineer)
Signature
Date
Mailing Address
City
State or Country (if foreign address)
ZIP Code
Telephone Number (include area code)
E-Mail Address (if available)
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 302-CA (Page 6)
June 2002

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