Coalition Provisional Authority (CPA)

Coalition Provisional Authority (CPA) Ministry of Communications Application for Broadcasting License or Satellite Broadcasting Uplink 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 Service Type (please choose option) One service per each application. AM FM TV Digital TV Digital Radio Satellite broadcasting uplink High Frequency (HF) Shortwave Facility Type (please choose option) Main transmitter and antenna location Auxiliary or spare transmitter location 1) Community of License; and if different, the location of studio City or town Desired Frequency (MHz or TV channel number) (For HF, list all frequencies desired) Transmitter and Antenna Location Address Coordinates Latitude: _______ ° _______ ' _______ " _______ Longitude: _______ ° _______ ' _______ " _______ Transmitter Power (kW) Antenna Gain (dBi) (Not applicable for AM and HF. Applicants for AM and HF stations are required to submit Annex A) Antenna Polarization (Not applicable for AM and HF. Applicants for AM and HF stations are required to submit Annex A) Antenna Elevation Above Average Terrain (meters) Not applicable for AM and HF. Applicants for AM and HF stations are required to submit Annex A) (Disregard for satellite broadcasting uplink) Radius of Signal Coverage (good listening or viewing) (Disregard for satellite broadcasting uplink) Approximate Population in above Coverage Area (Disregard for satellite broadcasting uplink) BROADCASTING INFORMATION Purpose of Station Political Affiliation Broadcasting Content Broadcasting Time Current Number of Employees Planned Number of Employees Investment in station to date, and the expected investment to construct an operational station Estimated First Year Operating Expenses 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 INTERESTED PARTIES 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 Printed name of person signing Title or position of person signing Signature Date Printed name of person signing Title or position of person signing Signature Date PREPARER’S CERTIFICATION, IF DIFFERENT THAN INTERESTED PARTIES. 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 applications 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