FCC License Application WorksheetThe FCC requires all applicants to furnish the information requested on this worksheet. The FCC will charge your credit card $205 for the Ship Station License (valid for ten years), and $55 for the Restricted Radio Operators Permit (valid for the life of the holder). This worksheet is available in PDF format by clicking here, or you can print this, the Internet version. Mail the completed worksheet, along with a check for the $75 processing fee to:
Note: By clearly printing the requested information in the spaces provided you are helping to ensure that your application will be processed as quickly and accurately as possible.1. Licenses Applied For (check either one or both): Ship Station License/Call sign:____ Restricted Radio Operators Permit:___2. If you are registered in the FCC Universal License System, or have been assigned a FRN number by the FCC, enter the ULS password or the FRN number & password, otherwise leave blank:
3. Current FCC licenses and call signs held by you (attach an additional sheet if necessary):
4. Your Name:_________________________________________________________________________________ 5. Street
Address:_______________________________________________________________________________ 7. Social Security Number:________- ______ - ___________ Date of birth:__________________(mm / dd / yy) 8. Telephone Number: (______) ______ - ___________ E-mail Address:__________________________________ 9. Boat Name:___________________________________________________________________________ 10. Documentation/registration #____________________________________________________________ 11. Credit Card Number:__________________________________________ Security Code1________________ 12. Credit Card Type (MasterCard, Visa, etc.):___________________________ Exp. Date: ________________(mm / dd / yy) 13. Name exactly as it appears on the
card: __________________________________________________________
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use Date filed with FCC:_________________ Date FCC Issued License:___________________ Ship Station License FCC File #: _________________ Operator Permit FCC File #: ____________________ Call sign issued:____________________ MMSI number issued:___________________________ Electronic filing fee paid to DSR: Cash / Check Number:______________ Date:____________ 1 The Security code is the last three numbers printed on the signature block on the back side of your card. |
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