Television License Exemption Declaration Form

Television License Exemption Declaration Form
Use this form to declare that you qualify for a television license exemption and provide the details needed to review your declaration.
Exemption Applicant Details
Full Name
First NameMiddle NameLast Name
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Television License Exemption Declaration
Reason for Exemption
Other valid exemption reason
Declaration Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Declaration Confirmation
Supporting Information
Date exemption applies from
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Explanation or additional details
Preferred contact method
Should be Empty: