1. Type of measurements needed (select one or both):

Antenna Proof/Field Intensity/Harmonic Emissions Measurement

Call Sign: Frequency:

City Of License: State: Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
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Please contact me as soon as possible regarding this matter

Where should the completed report be sent?

Frequency: Power:

Antenna System: Non-Directional Directional
Number of Towers:

Transmitter Manufacturer:

Transmitter Model:

Transmitter Site Location (can be coordinates as listed on license):

Nearest Major Intersection:

Critical Hours Facility: (Fill-in only the data that changes from "Day Mode" for this mode of operation.)

Frequency: Power:

Antenna System: Non-Directional Directional
Number of Towers:

Transmitter Manufacturer:

Transmitter Model:

Transmitter Site Location (can be coordinates as listed on license):

Nearest Major Intersection:

Frequency: Power:

Antenna System: Non-Directional Directional
Number of Towers:

Transmitter Manufacturer:

Transmitter Model:

Transmitter Site Location (can be coordinates as listed on license):

Nearest Major Intersection:

Enter any additional comments in the space provided: