Federal Communications Commission
Washington, D.C. 20554
March 2005
FOR FCC USE ONLY
 
Change in Official Mailing Address for Broadcast Station

Read Instructions/FAQ before filling out form

FOR COMMISSION USE ONLY
FILE NO.

1. Legal Name of the Licensee

Mailing Address


City
State or Country (if foreign address)
ZIP Code
-
Telephone Number (include area code)
E-Mail Address (if available) 
FCC Registration No

If the above fields do not contain the desired values, use the ‘Change Account Address’ button to go to the Account Maintenance screen where you can make changes for this CDBS account.

[Change Account Address]

2. Enter the station information for each facility this address change affects.

[Enter Station Information]



I certify that the statements in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I acknowledge that all certifications and attached Exhibits are considered material representations.

Typed or Printed Name of Person Signing
Typed or Printed Title of Person Signing
Signature
Date

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1)), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503).