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Proof of Amateur Activity

NTC proof of amateur activity for operator certificate

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Office of the President

NATIONAL TELECOMMUNICATIONS COMMISSION
National Capital Region
Quezon City
INFORMATION SHEET

INFORMATION SHEET
Any deliberate emission or distortion of material facts may give sufficient cause for denial of application.
1.

Name

_____________________________________________________________________ __________
(Surname)
(First Name)
(Middle Name)
(Alias)
2.
Change of name (if court action, give details) _______________________________________ __________
3.
Birth date ________________ Birth Place _____________________________________________________
4.
Citizenship _____________________, if naturalized, state previous citizenship, place date and Naturalization
Certificate No. _______________________________________________________________
5.
Physical Description: Sex: ____________Height (cm) _____________Weight (kg) ___________________
6.
Civil Status: ____________
Name of Spouse: ______________________________________________
7.
Name of Mother: ______________________
Occupation: _______________________________
8.
Name of Father: _________________________
Occupation: ________________________
9.
Name of Brothers and Sisters:_____________________________
______________________________
10.
Home Address: _______________________________________________________________ __________
Tel. No. _____________________
_____ Cell Phone No.
11.
Place of Residence since birth: ________________________________________________________________
12.
Employment:
Name of Employment/Company/Office: _____________________________________________ __________
Name of Business: _____________________________________________________________ __________
Designation/Position: ___________________________________________________________ __________
Business Address: _____________________________________________________________ __________
Telephone No. ___________________________ Fax No._____________________________ __________
13.
Schools Attended:
Name of School
Location
Course/Degree Date
Secondary:____________________________________________________________________________
College: ______________________________________________________________________________
Others: _______________________________________________________________________________
14.
List of Organization of which you are/have been a member (Schools, Civic or Religious Organization):
Organization
Address
Position
Inclusive Dates
____________________________________________________________________________ __________
Have you been arrested, convicted for any violation of laws or charged in any administrative case? ____,
if yes, state the name of court, nature of offense and disposition of the case
____________________________________________________________________________ __________
I CERTIFY that the foregoing are true and correct to the best of knowledge and belief and I AGREE that any
misstatement or omission as to the material fact(s) will constitute ground for immediate denial of my application.
Signed at ____________________________________________ Date ___________________ __________

_______________________________
(Name and Signature of Applicant)
Subscribe and sworn to before this ________th day of _________________________________ __________
affiant having his/her Residence Certificate No. _______________________________________, issued at
______________________________________ issued on _______________________________ __
Doc. No.
Page No.
Book No.
Series No.

______________
______________
______________
______________

NOTARY PUBLIC
 
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