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Approved by OMS -
3060-0096
Expires 07/31/93
See page two for information
regarding public burden estimate.
Application for Ship Radio Station License
A. CHECK BLOCK "A" ONLY IF SHIP IS RECREATIONAL OR VOLUNTARILY EQUIPPED. Complete applicable items 1thru 13and sign
application. You will automatically be authorized for VHF (156-158 MHz) & Class C EPIRB (156.75-156.8 MHz). Additional equipment other
than VHF & EPIRB must be requested in Item 16.
B. CHECK BLOCK "B" ONLY IF SHIP IS COMPULSORY EQUIPPED (REQUIRED TO BE RADIO EQUIPPED). Complete applicable
items I thru 18 and sign application. You will only be authorized for the specific category of transmitters that you have checked in Item 16.(See
instruction16) '.
1. Type of Applicant (Ckleck only one)
§
(A)Association I 14.Ship
D (I) Individual . (P) Partnership
D (C) Corporation (G) Governmental Entity
2. ApplicanVLicensee Name (See instruction)
FEDERALCOMMUNICATIONSCOMMISSION
D
D
DBAName (See instruction)
3. MailingAddress (Number and Street, P.O. Box or Rt. No.)
City
State
ZIP Code
4. Additional Partners
5. Purpose of Application
D NewStation D Modification D Renewal
6. Type of License{Check o~one)
D (R) Regular U (F) Fleet (No. of ships) -
D (P) Portable (Give required showing)
7. Name of Ship (See instruction)
8. Official Number of Ship (Coast Guard Documentation No.or State
Registration No.): Ifnone, see instruction.
9. Call Sign
(See inst.ruction)
10. Class of Ship (See instruction)
(~) General: (B) Specific:
11. Relationship of Applicant to Ship (Check only one)
D (A) Owner and/or Operator
D (B-)Other (Specify)
12. International Communications: (See instruction)
(A) Will Ship make international voyages?
(B) Will Ship communicate with foreign coast sta-
tions other than those located in Canada or Mexico?
13. (A) Are you requesting a Ship Station Identity
(9digit number) to be used with Digital Selective
Calling Equipment?
(B) Haveyou been assigned a Ship Station Iden-
tity Number for,this Ship?
If YES, show number
adioRequirementCategories(Seeinstruction) ,
D
(A) Radiotelegraph Station Required by Title Ill, Part 11ofthe
Communications Act or Safety of Life at Sea Convention.
D
(B) Radiotelephone Station Required by Title Ill, Part 11of the
Communications Act or Safety of Life at Sea Convention,
D (C) Radiotelephon~ Station Required byTitle Ill, Part III of the
Communications A~t.
0 (D) Radiotelephone Station Required by the Great Lakes Radio
, Agreement.
D (E) Radiotelephone Station Required by the VesselBridge-To-
BridgeRadiotelephoneAct.
15. Gross Tonnage and/or Len!;}thof Ship (See instruction)
(A) Gross Tons: (B) Feet:
16. Category of Transmitters (See instruction}
Check No. (Categories)
VHF/FM Radiotelephone(I 56-158MHz)& EPIRB(156.75-156.8MHz)
EPIRB (121.5and/or 243MHz) ClassA,B. or S
SSBRadiotelephone(1600-4000 kHz)
SSBRadiotelephone(4000-23000kHz)
Radar(2900-3100MHz) and;or (9300-9500MHz)
Radar(14.0-14.05GHz)
Radiotelegraph(2000-27500kHz) Except Direct Printing
Radiotelegraph(2000-27500kHz) Direct Printing (NBDP/SITOR)
Radiotelegraph(405-535kHz)
Survival Craft (500kHz) (8364kHz)
RTTY-Radioprinter (Under 1600GrossTons)
AMTS (216-220MHz)
Facsimile
Satellite(16365-1644MHz)
EPIRB (1645.5-1646.5MHz)
EPIRB (406-406.1MHz)
On-Board(457.525-467.825MHz)
OTHER (Seeinstruction)
17. Radiotelegraph Morse Working Channel Series
(2000-27500 kHz):
W_-,W_-
18. Numerical ShipcStation Identification
(A) Selective Call .
Number (5 digits)
(B) INMARSAT
Number (7 digits)
CERTIFICATION, READ CAREFULLY BEFORE SIGNING
1. Applicant waivesany claim to the use of any particular frequency regardless of prior use by license or otherwise.
2. Applicant willhave unlimited access to the radio equipment and willcontrol access to exclude unauthorized persons.
3. Neither applicant nor any member thereof is a foreign government or representative thereof.
.
4. Applicant certifies that all statements made inthis application and attachments are true, complete, correct and made in good faith.
5. Applicant certifies that the signature is that of the individual, or partner, or officer or duly authorized employee ofa corporation,or officer who isa
member of an unincorporated association, or appropriate elected or appointed official on behalf of a governmental er:'tity.
WILLFULFALSESTATEMENTSMADEONTHISFORMAREPUNISHABLEBYFINEAND/ORIMPRISONMENT.U.S.CODETITLE18,SECTION1001
Typed/Printed Signor Name:
Signature:
Telephone No:
Date:
FCC Form 506, Page 1
February 1991
YES NO
D D
D D
YES NO
D
D
D
D