Form-No.-NTC-1-04-APPLICATION-FOR-SHIP-SHIP-EARTH-STATION-LICENSE-CARGO-SHIP-SAFETY-RADIO-CERTIFICATE-TEMPORARY-PERMIT-FERRYING PERMIT

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Republic of the Philippines Form No.

NTC 1-04
NATIONAL TELECOMMUNICATIONS COMMISSION Revision No. ____ __01
Revision Date 03/31/2021
BIR Road, East Triangle, Diliman, Quezon City

APPLICATION FOR SHIP/SHIP-EARTH STATION LICENSE/CARGO SHIP


SAFETY RADIO CERTIFICATE/TEMPORARY PERMIT/FERRYING PERMIT
INSTRUCTIONS:
(1) Accomplish this application form properly, in ALL CAPS, handwritten or computer-printed.
(2) Attach the complete requirements including supporting documents. For the List of requirements,
please refer to the NTC Citizen's Charter 2021 Second Edition at NTC website: www.ntc.gov.ph
(3) Check (✔) appropriate box. Indicate "N/A" for items not applicable.

TYPE OF APPLICATION TYPE OF PERMIT/LICENSE/CERTIFICATE


NEW SHIP STATION LICENSE
RENEWAL SHIP-EARTH STATION LICENSE
MODIFICATION due to (USE FORM B) CARGO SHIP SAFETY RADIO CERTIFICATE
TEMPORARY PERMIT
FERRYING PERMIT
NO. OF YEARS TRADING/ROUTE Ship Aircraft
DOMESTIC OTHERS, specify
INTERNATIONAL

APPLICANT'S DETAILS
Applicant
Unit/Rm/Bldg No. Street
Barangay City/Municipality
Province Zip Code
Contact Number Email Address
PARTICULARS OF STATION
Name of Ship/Vessel Call Sign
MMSI No. Station License No.
IMO No. Validity (mm/dd/yy)
PARTICULARS OF EQUIPMENT (FOR MULTIPLE STATION/EQUIPMENT, USE FORM A)
Radio Equipment Make Type/Model Serial Number Power Output

DETAILS OF RADIO OFFICER(S)/OPERATOR(S)


Name
Certificate Number
Validity (mm/dd/yy)
DECLARATION
I hereby declare that all the above entries are true and correct. Under the Revised Penal Code, I shall be held liable for any willful false statement(s) or
misrepresentation(s) made in this application form that may serve as a valid ground for the denial of this application and/or cancellation/revocation of the permit
issued/granted. Further, I am freely giving full consent for the collection and processing of personal information in accordance with Republic Act No. 10713, Data
Privacy Act of 2012.

Signature over Printed Name of Applicant /


Duly Authorized Signatory/Representative

Date Accomplished

THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED

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