Revised Form No.

1-A-81 (This application form is not for sale)

Republic of the Philippines

NATIONAL TELECOMMUNICATIONS COMMISSION
Regional Office No. 1
L. Dacanay Avenue, Barangay San Francisco, City of San Fernando, La Union ID Picture
Tel No. (072) 607-5654 Fax No. (072) 607-5656 1x1

APPLICATION FOR COMMERCIAL/ NON-COMMERCIAL

RADIO OPERATOR EXAMINATION
(Please check appropriate type and class of examination applied for)
Elements to be taken
 Radiotelephone
 Radiotelegraph
 Amateur (“A”) (“B”) (“C”)
 Others _________________

DATE OF EXAMINATION: PLACE OF EXAMINATION:

1. Applicant: (Print)
(Last) (First) (Middle)
2. Address: Tel No.
3. Birthplace: Birthdate:
4. Citizenship: Civil Status:
5. School last attended: Course Taken:
6. Year graduated: Present Occupation:
7. Employed by: How long in present job:
8. Previous examination taken: Place of exam: Date of exam:
9. If License/Permit holder, state type/class:
Permit/License Number: Expiration date:
10. Records and Notations:
11. Copy the following paragraph in your OWN HANDWRITING using the space provided hereunder;
“WILLFUL FALSE STATEMENT MADE ON THIS APPLICATION IS PUNISHABLE UNDER ARTICLE
138 OF THE REVISED PENAL CODE BY A MINIMUM OF SIX (6) YEARS IMPRISONMENT”

12. Processing Notations:

TIN:
Res. Cert. No.:
Issued at:
Issued on:

Signature of Applicant
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(Do not tear nor detach unless properly processed and approved)
ID Picture
ADMISSION SLIP 1x1
To: The Chief, ROEC

Date of Exam: Place of Exam:

Please Admit (Name)
Address of Examinee
To take examination for
SPECIAL INSTRUCTIONS:
1. Please present this ADDMISSION SLIP to
The Examiner at the place of examination
2. Be at the place of examination not later than DANILO O. CUENCA, PECE, REE
7:00 AM on the Exam Day. Regional Director