Republic of the Philippines NTC Form No.

: APPL-15___
NATIONAL TELECOMMUNICATIONS COMMISSION Reference No.: __________
BIR Road, East-Triangle, Diliman, Quezon City

APPLICATION FOR RADIO OPERATOR CERTIFICATE

INSTRUCTIONS: All blanks must be filled up properly. Indicate “N/A” for the items not applicable. Duly
accomplished form must be submitted with required/supporting documents. Print all entries in
block or CAPITAL LETTERS.

1PHN 1RTG PROC-AIRCRAFT/RMAP RLM GROC

2PHN 2RTG PROC-SHIP SROP OTHERS
3PHN 3RTG PROC-SLP AMATEUR ____________

TYPE: New Ren NUMBERS OF YEARS: One Two Three

1 APPLICANT : ______________________ ________________________ _____________________

Surname First Name Middle Name
2 ADDRESS : ____________________________________________________________
No./ Streets/ Road Barangay
____________________________________________________________
City/Municipality Province Zip Code
3 CONTACT NO. (S) : _____________ EMAIL ADD: ___________________________________
4 HEIGHT (cm) : ________ WEIGHT (kg) _________ GENDER: _________ STATUS:______
5 PLACE OF EXAM/ SEMINAR : ____________________ DATE: ______________ RATINGS: ________
6 NAME OF EMPLOYER : __________________________________BIRTHDATE:________________
7 ADDRESS : ____________________________________________________________
8 POSITION : ____________________________________________________________

9 SUPPORTING DOCUMENTS/ REQUIREMENTS :

I. NEW
a. Original copy of report of rating or certified true copy of result forPHN/RTG/RROC/AMATEUR
or certificate of completion of seminar from NTC for RLMOP/SROP/SLP/GROC.
b. Three (3) pcs. 1 x 1 ID Picture
c. Duly accomplished information sheet (handwritten)
d. Photocopy of any valid Government issued ID
e. Service record. Certificate of good moral character and Certification as radio operator or one
who operates a radio station duly signed by the Head of Human Resource Unit of the agency.
(for GROC).

II. RENEWAL
a. Original copy of certificate to be renewed.
b. Three (3) pcs. 1 x 1 ID Picture

10 CERTIFICATION

I HEREBY CERTIFY that all above entries are true and correct and that I shall be held liable for any willful false
statements made in this application under the Revised Penal Code. Any false statement or misinterpretation made
in connection with this application shall constitute a valid ground for the denial of this application and/or
cancellation/revocation of the permit to be granted.

______________________________________ ______________
Signature over Printed Name of Applicant Date

NO: ___________
OR DATE:______,20__
AMOUNT: _____________
_____________________
CASHIER

THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED

Revision No.:

Revision Date:
NTC REGIONAL OFFICE NO.: ____1_____________________________________
Office Address: Dacanay Road, Brgy San Francisco, San Fernando City, La Union
Contact No.: _(072) 607-5654________________________________________
Fax No.: __(072) 607-5656_______________________________________
E-mail Address: _ntc.ilocosregion@ntc.com.ph_________________________
 Republic of the Philippines
NATIONAL TELECOMMUNICATIONS COMMISSION
Region 1-ILOCOS REGION
Airport Compound, L. Dacanay Ave., Barangay San Francisco
2500 San Fernando City, La Union

INFORMATION SHEET

Instruction:
1. Print with your own hand writing and write legibly.
2. Answer all questions completely. If the question is not applicable, write “N/A”. write “Unknown” if you
do not know the answer from personal regards.
3. Any deliberate omission or distortion of material facts may give us sufficient cause for denial of your
application.
1 ________________________ _____________________ _________________ ______________
(Last Name) (First Name) (Middle Name) (Alias)
2 Home Address: __________________________________________________________________________________
3 Employment/Business Name: ________________________ Address: _______________________________
4 Telephone Num (Residence): ________________________ Business Tel No.: ________________________
5 Change in Name (If by court action, give details): _______________________________________________________
6 Birthday: ________________ Birthplace: __________________ Civil Status: ___________________________
7 Sex: _________ Height: ______________ Weight: ________________ Civil Status: __________________
8 Spouse: ________________ Occupation: ______________________ Employer: _______________________
9 Father: _________________ Occupation: ______________________ Employer: _______________________
10 Mother: _________________ Occupation: ______________________ Employer: _______________________
11 Sisters: _________________ Occupation: ______________________ Employer: _______________________
_________________ Occupation: ______________________ Employer: _______________________
12 Brothers: ________________ Occupation: ______________________ Employer: _______________________
________________ Occupation: ______________________ Employer: _______________________
13 Place of residence(s) since birth:
Location Inclusive Dates
_______________________________________________________________________________________________
14 School Attended: Name of School Location Grade/Year Inclusive Dates
a. Secondary ___________________ _________________ _________________ __________________
b. College ___________________ _________________ _________________ __________________
c. Others ___________________ _________________ _________________ __________________
15 List of Organization(s) of which you are/have been a member (Social,student,labor,civic, or religion ass’ns.)
Name of the Organization Address Inclusive Dates
__________________________ ________________________________ _____________________________
__________________________ ________________________________ _____________________________
16 Previous Employment(s):
Company/Employer Address Inclusive Dates
__________________________ ________________________________ _____________________________
__________________________ ________________________________ _____________________________
17 Arrest Records and Conduct:
Have you ever been arrested, indicated or convicted for any violation of laws or charges in any administrative
case(s)? ________ If so, state name of courts, nature of offense and disposition of the case(s).
_______________________________________________________________________________________________
I CERTIFY THAT THE FOREGOING ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND I
AGREE THAT ANY MIS-STATEMENT OR OMISSION ON ANY MATERIAL FACTS(S) WILL CONSTITUTE FOR IMMEDIATE
DENIAL OF MY APPLICATION.
Signed on: _________________
__________________
(Applicant Signature)

SUBSCRIBED AND SWORN TO before me this ____ day of ____, 20__

Affiant exhibited his/her Community Tax Certificate No. ___________
Issued at ______________ on __________________.

NOTARY PUBLIC