FCC License Application Worksheet 

The 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:_______________________________________________________________________________ 

6. City:________________________________________________ State:_______Zip:________________________ 

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: __________________________________________________________
 

This section for office 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.