Ship Radio Licence Application Form

Applicant or Company Name

First NameLast Name

Contact Person Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Contact Method

Vessel Name

Vessel Type

Call Sign

Registration or Official Number

Home Port

Gross Tonnage or Vessel Size

Primary Operating Area

Radio equipment carried on board

Does the vessel already have a radio licence?

Licence or registration reference

Intended use of the radio equipment

Additional equipment details or notes

Additional onboard communication or distress devices