ANTE Form No: APPL-AS Republic of the Philippines Reference Ne: NATIONAL TELECOMMUNICATIONS COMMISSION BIR Road, East-Triangle, Diliman, Quezon City APPLICATION FOR RADIO OPERATOR CERTIFICATE INSTRUCTIONS: All blanks must be filed up properly. Indicate "N/A" for tems not applicable. Duly accomplished form must be submitted with required/supporting documents. Print all entries in block of CAPITAL LETTERS. TPROC - SHIP “Jproc - sip NUMBER OF YEARS: 41 APPLICANT : Simane Fea Tad Wane 2 ADDRESS ToT ST Road aay Siena Fis Ta tole SCONTACTNO.(S) = EMAIL ADD: 4 HEIGHT (em) : WEIGHT kg) ‘GENDER: STATE 5 PLACE OF EXAM SEMINAR: DATE: RATINGS: 6 NAME OF EMPLOYE! 7 ADDRESS 8 POSITION 8 SUPPORTING DOCUMENTS/ REQUIREMENTS : Brana 1 NEW ‘@. Original copy of report of rating or certified true copy of result of rating for PHN/RTG/RROC/AMATEUR or certificate of completion of seminar from NTC for RLMOP/SROP/SLPIGROC. Three (3) pcs. 1 X 1 ID Picture ‘Duly accomplished information sheet (handwritten) Photocopy of any valid Government issued ID ‘Service record, Certificate of good moral character and Certification as radio operator or one who operates a radio station duly signed by the Head of Human Resource Unit of the agency. (for GROC) gag Ul, RENEWAL, @. Original copy of certificate to be renewed, b. Three (3) pes. 4X 1 ID Picture 10 CERTIFICATION IHEREBY CERTIFY that all above entries are true and correct and that | shall be held liable for any witful false statements made inthis application under the Revised Penal Code. Any false sialement or misrepresentation made in ‘connection wit this appitcation shall constitute a valid ground forthe denial of his appication andlor cancellation! revocation of the permit to be granted, Signature over Printed Name of Applicant Date THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCEDNTC REGIONAL OFFICE NO.: NCR Office Address: __BIR RD. EAST TRIANGLE DILIMAN QUEZON CITY ‘Contact No. 924-4010 Fax No. 924-3770 E-mail Address: ‘ntcner@yahoo.com