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1. | Legal Name of the Applicant |
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Mailing Address |
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City |
State or Country (if foreign address) |
Zip Code - |
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Telephone Number (include area code) |
E-Mail Address (if available) |
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FCC Registration Number: |
Call Sign |
Facility ID Number 11951 |
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2. | Contact Representative (if other than licensee/permittee) |
Firm or Company Name |
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Mailing Address |
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City |
State or Country (if foreign address) |
ZIP Code - |
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Telephone Number (include area code) |
E-Mail Address (if available) |
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3. | Purpose: Consummation Notice |
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Extension of Consummation | ||||||||||||
Notification of Non-consummation | ||||||||||||
4. | Consummation for: Assignment of License and/or Permit |
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Transfer of Control |
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5. |
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Lead Facility ID: | ||||||||||
6. |
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I certify that the statements in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I acknowledge that all certifications and attached Exhibits are considered material representations.
Typed or Printed Name of Person Signing |
Typed or Printed Title of Person Signing |
Signature |
Date |
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).