NTC Form No.

: APPL-IS
Republic of the Philippines
NATIONAL TELECOMMUNICATIONS COMMISSION Refercnce No:
BIR Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR RADIO OPERATOR CERTIFICATE

INSTRUCTIONS: All blonks must be filled up properly. lndicate "N/A" for items not applicoble. Duly
accomplished form must be submitted with required/supporting documents. Print
oll entries in block or CAPITAL LETTERS

lPHN lRTG ROC-ATRCRAFT/RMAP RROC-LAND MOBILE GROC

2PHN 2RTG RROC-SHIP SROP.GOV'T OTHERS

3PHN ROC - SLOP AMATEUR

NUMBER OF YEARS:

1. APPTICANT
Surname First Name Middle Name
2. ADDRESS

3. CONTACT NO.(S): EMAIT ADD:

4. DATE OF BIRTH (mm/ddlW): HEIGHT (cm) wElGHr (ks)
5. CIT|ZENSH|P : SEX:
6. PIACE OF EXAM/SEM|NAR: DATE (mm/dd/w) RATING:
7. NAME OF EMPLOYER :
8. ADDRESS
9. POSTilON
l0.suPPoRTrr{GTX)CUMENn;/REqU|REMENTS :
NEW
a. original/certified copy of report of rating for
PHN/RTG/AMATEUR or certificate of completion of seminar from
for RROC-LAND MOBILE/SROP-GOV'T/SIOP/GRoc.
NTC
b. Three (3) pcs. 1x1 lD Picture
c. Show of proof of anyvalid Government issued lD
d. Service record, Certification as radio operator or one who operates a radio station duly signed by the
Head of Human Resource Unit of the agenry. (for GROC only).
il. REI{EWAr
a. Original copy of certificate to be renewed
b. Three (3) pcs. 1x1 lD Picture
11. DECIAMTION OF APPLICANT

I HEREBY CERnFf thot oll above entries ore tue and coftect ond thot I shall be held liable for ony wilful folse
stotements mode in this opplicotion under the Revised Penol Code. Any foke stotement or misrepresentotion
mode in connection with this applicotion sholl constitute o valid ground for the deniol of this applicotion
ond/or revmotion of the permit to be granted. Furthe|, t am /ircely givinb specifrc, tntormed lndtcotlon q
my wlll ond lull cf,n*nt lw the allectlon ard prorf,sing ol my prmnal Inltmation tn occorddne with
Dota tuiva.y Act of 2072.

Signature of Applicant over Printed Name Date

NO:
OR DATE: 20

AMOUNT:

t-
THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED ! Revision t{o. : :
,- - -
ir-
I
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nevision Date:
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