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Licensee Contact Information

Contact Name & Address (If other than Licensee)

Items 16-26 These items identify the contact representative for the Licensee. This is usually the Licensee itself, the headquarters office

of a large company, the law firm or other representative of the Licensee, or the person or company that prepared or submitted the

Application on behalf of the Licensee. If there is a question about the Application, an FCC representative may communicate with the

Licensee’s contact representative.

Completion of the Licensee Contact Information section is required.

If, however, the Licensee Contact Information is the same in all respects as the Licensee Information provided in Items 1-14, check the

box located above Item 16 and do not complete the remaining items in this section.

If the Licensee Contact Information is not the same as the Licensee Information, then you must provide the information and complete

this section as follows:



Either the Individual Name (Item 16) or the Company Name (Item 17) is required.



If Individual Name (Item 16) is completed, then Company Name (Item 17) and Attention To (Item 18)

are optional.



If Company Name (Item 17) is completed, then either an Individual Name (Item 16) or Attention To

(Item 18) is required.



Either a PO Box (Item 19) or a Street Address (Item 20) is required. Both may be provided.



City, State and Zip Code are required (Items 21-23).



Telephone Number (including area code) is required (Item 24).



FAX Number and E-Mail Address are optional (Items 25-26).

Licensee Certification Statements

By signing this form, the Licensee certifies that the statements listed in this section are true, complete, correct, and made in good faith.

General Certification (4) is required for licenses for spectrum that is required by Sections 6103, 6401-6403 of the Middle Class Tax

Relief and Job Creation Act of 2012, codified at 47 U.S.C. §§ 309, 1413, 1451-1452, to be assigned by a system of competitive bidding

under 47 U.S.C. § 309(j) (e.g. radio service AH (AWS-H Block at 1915-1920 MHz and 1995-2000 MHz), radio service AT (AWS-3,

1695-1710 MHz, 1755-1780 MHz and 2155-2180 MHz), and radio service WT (600 MHz Band)). For purposes of this certification, the

term “reasons of national security” means matters relating to the national defense and foreign relations of the United States..

Items 27-29 These items must be completed. To be acceptable for filing, the Application (or Amendment or Withdrawal of a pending

Application) must be signed in accordance with Part 1 of the FCC Rules. The party signing must be a person authorized to sign the

Application. A paper original of the Application must bear an original signature; neither a rubber-stamped nor photocopied signature is

acceptable. For a Licensee filing electronically via ULS, the electronic signature shall consist of the name of the individual typed on the

Application as a signature.

License Authorization(s) To Be Included in the Filing

Item 30 In this column, list the Call Sign(s) of the licenses that are associated with the Application. Call signs are located on FCC

Authorizations.

Item 31 In this column, list the Radio Service Code for each Call Sign listed in Item 30. The Radio Service Code is a 2-letter code and

is located on FCC authorizations.

Item 32 In this column, provide the initial grant date of the license(s). The initial grant date is the date that the license was originally

granted by the Commission after an auction, even if the license was acquired in the secondary market. The initial grant date is not the

date on which the Commission granted an assignment or transfer of control of the license.

Item 33 In this column, indicate which designated entity benefits are associated with the license(s). Place a “B” in the field if the license

was granted with a bidding credit, a “C” if the license is a closed bidding or entrepreneur license, and/or an “I” if the license has

installment payments.

FCC 611-T – Instructions

August 2016 – Page 5

Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits Page 5

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