Station License Renewal Request Form

Station License Renewal Request Form
Submit your renewal request for your station license. Please complete all required fields to ensure timely processing.
Station Name
Station/License Identifier
Station Address/Location
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
License Holder or Organization Name
Primary Contact Person
First NameLast Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current License Expiration Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Renewal Reason or Details
I confirm that the information provided is accurate and complete to the best of my knowledge.
Should be Empty: