Coalition Provisional Authority (CPA) — Ministry of Communications (GOV-72436ce3)

Coalition Provisional Authority (CPA) Ministry of Communications Application for Fixed Service License Please submit one form for each station. Date of Application dd/mm/yyyy CPA File Number GENERAL INFORMATION Name of Applicant Address City, Postal Code Country Telephones Email Applicant’s Contact Representative Address City, Postal Code Country Telephones Email Application Purpose (please choose option) New Application Renewal of existing license. Major Modification Minor Modification Major Change in Licensed Facility Minor Change in Licensed Facility Major Amendment to Pending Application Minor Amendment to Pending Application Satellite Service Application (please choose option) Private Security Public Safety Business Other If Public Safety, select one or more: Police Fire Department Ambulance Other If Business or other, state the type of activity _________________________________. Facility Type (please choose option) Main transmitter and antenna location Auxiliary or spare transmitter location Community of License City or town Desired Transmitter Frequency (MHz or GHz, please indicate ) Receiver Frequency (MHz or GHz, please indicate ) Transmitter Modulation Type and Bandwidth Transmitter Location. Address Coordinates Latitude: _______ ° _______ ' _______ " _______ Longitude: _______ ° _______ ' _______ " _______ Receiver Location. Address Coordinates Latitude: _______ ° _______ ' _______ " _______ Longitude: _______ ° _______ ' _______ " _______ Transmitter Emission Bandwidth (MHz) Transmitter Output Power (Watts) Antenna Manufacturer and Model Number Antenna Azimuth and Elevation Antenna Gain in dBi, in both the transmitting and receiving bands, and Polarization Antenna Elevation (meters) INTERESED PARTIES INFORMATION List the applicant, and, if other that a natural person, its officers, directors, major stockholders and other entities with attributable interests, non-insulated partners and/or members. Name Citizenship Citizenship Percentage of Total Assets APPLICANT’S CERTIFICATION I certify that the statements in the application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. Printed name of person signing Title or position of person signing Signature Date PREPARER’S , IF DIFFERENT FROM APPLICANT, CERTIFICATION I certify that the statements in the application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. Printed name of person signing Title or position of person signing Signature Date Submit application to: Office of Spectrum Management Coalition Provisional Authority Ministry of Transportation and Communications Republican Palace -- Room S-204 Baghdad, Iraq DOD- DSN 318-239-5808/5809 Commercial (1) 781-280-5808/5809 Or e-mail to: frequencylicense@orha.centcom.mil