Fcc Form 611-T - Fcc Wireless Telecommunications Bureau Annual Report Related To Eligibility For Designated Entity Benefits Page 7
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9FCC Form 611-T
Approved by OMB
FCC Wireless Telecommunications Bureau
3060-1092
Annual Report Related To Eligibility
See 611-T Instructions
for Designated Entity Benefits
for public burden estimate
Licensee Information
1a) Purpose of Filing (Select only one):
) AR – DE Annual Report
) AM – Amendment
) WD – Withdrawal
(
(
(
1b) If this filing is for an Amendment (AM) or Withdrawal (WD), enter the File Number of the pending
File Number:
application currently on file with the FCC.
_________________________
FRN
2) FCC Registration Number:
Entity
3) Licensee is a(n) (Select One):
(
) Individual
(
)Unincorporated Association
(
)Trust
(
)Government Entity
(
)Corporation (
)Limited Liability Company
(
) General Partnership
(
) Limited Partnership
(
) Limited Liability Partnership
(
) Other: ___________________________________________________________________________________________________________
Licensee Name
4) Licensee Name (if entity):
5) Licensee Name (if individual):
First:
MI:
Last:
Suffix:
6) Attention To:
Address
7) P.O. Box:
And
8) Street Address:
/Or
9) City:
10) State:
11) Zip Code:
12) Telephone Number: (
)
13) FAX Number: (
)
14) E-Mail Address:
15) Demographics (Optional):
Race:
Ethnicity:
Gender:
(
)American Indian or Alaska Native
(
)Hispanic or Latino
(
)Male
(
)Asian
(
)Not Hispanic or Latino
(
)Female
(
)Black or African-American
(
)Native Hawaiian or Other Pacific Islander
(
)White
FCC 611-T
August 2016 – Page 1
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