Government of Barbados

mist.forms@barbados.gov.bb

Level 3 & 4 Baobab Tower, Warrens, St. Michael, BB

1(246) 535-1284

APPLICATION FOR PRIVATE TWO WAY RADIO NETWORK LICENCE

Is this application for:

Family Radio Service

General Mobile Radio Service

PART A: APPLICANT INFORMATION

Name (if individual)

Nationality (if individual)

Phone Number

Is application submitted with cheque?

Yes

Equipment Dealer Information

Equipment Purchased from:

Date of Purchase:

Contact Name

Dealer’s Licence No

Phone Number

PART B: TECHNICAL INFORMATION

Station Information

Location

Purpose of Communication

Portable Radio Equipment Information

Is the Equipment type-approved?

Yes

Total No. of Radios

List of associated Radio equipment:

Field 1

Field 2

Field 3

PART C: DECLARATION OF APPLICANT

To: The Ministry responsible for Telecommunications

*I/We hereby declare that the information and particulars given by me/us in this form and in the documents submitted are to the best of *my/our knowledge true and correct.

Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.