A.R.C.A. PACKET Frequency Coordination Application Form
Please See Instructions
Band:10m____6m____2m____222____420____440____902____1240____MW____ (1)	
System Information
Output Freq: 	______________________(2)		Input Freq:	________________________(3)	
City: 	______________________(4)	
Alias:	______________________(5)		Callsign:	________________________(6)	
Location:	_____________________________________________________________________(7)	
Region:	______________________(8)		County:	________________________(9)	
BAUD:	______________________(10)		System:	________________________(11)	
Network:	______________________(12)		Software:	________________________(13)	
IP Address:	____.____.____.____   (14)		FQDN:	________________________(15)	
Latitude:	__ __ __ __ . __ __   (16)		Longitude:	__ __ __ __ __ . __ __  (17)	
MountainTop:	______________________(18)			
Freq #2:	______________________(19)		Freq2 BAUD:	________________________(20)	
Freq #3:	______________________(21)		Freq3 BAUD:	________________________(22)	
Freq #4:	______________________(23)		Freq4 BAUD:	________________________(24)	
Power Out:	______________________(25)		Emission:	________________________(26)	
Ant Type:	______________________(27)		Ant Gain:	________________________(28)	
Ant Bearing:	______________________(29)		Ant Pol:	________________________(30)	
Ant Height:	______________________(31)		Ant Elev:	_________________________(32)	
SPONSOR  Information 
Name:	____________________________(33)		Callsign:	______________________(34)	
Address:	___________________________________________________________________________(34)	
City:	____________________________(36)		State:	__ __(37)	Zip:	_______________(38)	
Phone:	(__ __ __)  __ __ __  - __ __ __ __  (39)	
E-Mail:	___________________________________________________________________________(40)	
OWNER  Information 
Name:	____________________________(41)		Callsign:	______________________(42)	
Address:	___________________________________________________________________________(43)	
City:	____________________________(44)		State:	__ __(45)	Zip:	_______________(46)	
Phone:	(__ __ __)  __ __ __  - __ __ __ __  (47)	
E-Mail:	___________________________________________________________________________(48)	
CONTACT  Information 
Name:	____________________________(49)		Callsign:	______________________(50)	
Address:	___________________________________________________________________________(51)	
City:	____________________________(52)		State:	__ __(53)	Zip:	_______________(54)	
Phone:	(__ __ __)  __ __ __  - __ __ __ __  (55)	
E-Mail:	___________________________________________________________________________(56)	
SITE OWNER 
Name:	___________________________________________________________________________(57)	
SUBMITTER  Information 
Name:	_________________________(58)		Callsign:	______________________(59)	
Phone:	(__ __ __)  __ __ __  -  __ __ __ __  (60)	
E-Mail:	___________________________________________________________________________(61)	
REMARKS (62)
	
Date of Approval	_________________	

Signature:	_________________________(63)	Date of Application:	_________________(64)