| Note: This is an HTML rendition of a document composed in WordPerfect 6.0. You may download the original document here. |
Originator Information Incident I.D. Number: _______________________________________Date: _______________________________________________ |
Interference Recipient Information Licensee Contact: __________________________________________________________________________________________________________________ Licensee Name: ___________________________________________________________________________________________________________________ Address: ___________________________________________________________________________________________________________________ City:__________________________________________________ State:______________Zip___________________________________ Phone:___________________________________ Fax:_______________________ E-mail:_____________________________________ Service Provider Contact:_____________________________________________________Phone:_______________________________ Description and Location of System Affected Call Sign:________________________________ Station Class(es):______________________________________________________ Emission Designator:_________________Receiving Frequency(ies):_____________________________________________________ Transmitter Address ___________________________________________________________________________________________________________________ Transmitter City/State:___________________________________Coordinates:_____________________________________________ Equipment Manufacturer ___________________________________________________________________________________________________________________ Interference Identification and Description Date of Interference Commencement:_________________________________ Type of Interference:______________________________________________________________________________________________ Repetition:______________________________________ Duration:________________________________________________________ |
Interferor Information Licensee Contact __________________________________________________________________________________________________________________ Licensee Name __________________________________________________________________________________________________________________ Address __________________________________________________________________________________________________________________ City:_________________________________________ State:_____________ Zip:_________________________________________ Phone:___________________________________ Fax:_____________________________ E-mail:______________________________ Service Provider Contact:_______________________________________________ Phone:__________________________________ Description and Location of Interfering System Call Sign:________________________________ Station Class(es):_____________________________________________________ Emission Designator:_______________________ Transmitting Frequency(ies):__________________________________________ Transmitter Address __________________________________________________________________________________________________________________ Transmitter City/State:_____________________________________________ Coordinates:________________________________ Equipment Manufacturer __________________________________________________________________________________________________________________ |
AAR Action Initiated to Resolve Interference Cause of Interference __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Action Taken by LIcensee __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Interference Resolution Recommendation __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Technical Assistance Received __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Request for FCC Compliance/Enforcement Action FCC Action Recommendation _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Recipient and Interferer Notification Date _________________________________________________________________________________________________________________ Attachments: [ ] Technical Exhibits [ ] Correspondence Exhibits [ ] Mediation Log Exhibit |