Request for Administrative Update of FCC License
$130.00 (Processing Fee)
Call Sign: ${modification_call_sign}
Expiration: ${modification_expiration}
Licensee Name: ${legal_licensee_name}
Contact Name: ${contact_person_name}
Address: ${address_1} ${address_2}
City, State & Zip: ${city} ${state}, ${zip}
Phone: ${phone}
Licensee Federal Tax ID#: ${licensee_federal_tax_id}
Fax: ${invoice_fax}
Email: ${invoice_email}
Additional Comments: ${additional_comments}