0288-EX-CN-2017

Filing overview

442 application form

FCC FORM 442 - FEDERAL COMMUNICATIONS COMMISSION APPLICATION FOR NEW OR MODIFIED RADIO STATION UNDER PART 5 OF FCC RULES - EXPERIMENTAL RADIO SERVICE (OTHER THAN BROADCAST)

Approved by OMB 3060 - 0065

442 application form - Applicant Type

Applicant is:

Corporation

442 application form - Application Purpose

Application is for:

NEW LICENSE

442 application form - Certification

Applicant certification

Public reporting burden for this collection of information is estimated to average four (4) hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to the Federal Communications Commission, Records Management Branch, Paperwork Reduction Project (3060-0065), Washington DC 20554. DO NOT send completed applications to this address. Individuals are not required to respond to this collection unless it displays a currently valid OMD control number.

Applicant certification

NOTIFICATION TO INDIVIDUALS UNDER PRIVACY ACT OF 1974 AND THE PAPERWORK REDUCTION ACT OF 1980

Applicant certification

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, P.L. 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3), AND THE PAPERWORK REDUCTION ACT OF 1980, P.L. 96-511, DECEMBER 11, 1980, 44 U.S.C. 3507.

Applicant certification

WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(A)(1)), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503).

Applicant certification

Information requested through this form is authorized by the Communications Act of 1934, as amended, and specified by Section 308 therein. The information will be used by Federal Communications Commission staff to determine eligibility for issuing authorizations in the use of the frequency spectrum and to effect the provisions of regulatory responsibilities rendered by the Commission by the Act. Information requested by this form will be available to the public unless otherwise requested pursuant to 47 CFR 0.459 of the FCC Rules and Regulations. Your response is required to obtain this authorization.

Classification:

Authorized employee

Name of Applicant:

Axonics Modulation Technologies, Inc.

Signature (Authorized person filing form):

Franklin Portillo

Signature Date (Authorized person filing form):

04/19/2017

Title of Person Signing Application:

Product Assurance Manager

442 application form - Contact Information

First Name:

Rinda

Last Name:

Sama

Phone Number:

949-396-6322

Title:

VP, Operations, Regulatory and Quality

442 application form - Drug Abuse Question

APPLICANT ANTI-DRUG ABUSE CERTIFICATION: By checking "YES", the individual applicant certifies that he or she is eligible for this license. This requires that he or she is not subject to a denial of federal benefits, including FCC benefits, as a result of

Yes

442 application form - Environmental Impact

Would a commission grant of this application come within Section 1.1307 of the FCC Rules, such that it may have a significant environmental impact? If "YES", include as an exhibit an Environmental Assessment as required by Section 1.1311.

No

442 application form - Estimated Duration

Give an estimate of the length of time that will be required to complete the program of experimentation proposed in this application:

36 Months

442 application form - For Modification indicate below

Callsign:

WI2XYC

442 application form - Foreign Government

Is applicant a foreign government or a representative of a foreign government?

No

442 application form - Foreign Government Use

Is this authorization to be used for the exclusive purpose of developing radio equipment for export to be employed by stations under the jurisdiction of a foreign government? If "YES", include the contract number and the name of the foreign government con

No

442 application form - Government Contract

Is this authorization to be used for fulfilling the requirement of a government contract with an agency of the United States Government? If "YES", include as an exhibit a narrative statement describing the government project, agency and contract number.

No

442 application form - License Denied or Revoked

Has applicant or any party to this application had any FCC station license or permit revoked or any application for permit, license or renewal denied by this Commission? If "YES", include as an exhibit a statement giving call sign of license or permit rev

No

442 application form - Mailing Address

Attention:

Rinda Sama

City:

Irvine

E-Mail Address:

rsama@axonicsmodulation.com

State:

CA

Street Address:

7575 Irvine Center Drive, Suite 200

Zip Code:

92618

442 application form - Manufacturer

Equipment 1 Experimental

Yes

Equipment 1 Manufacturer

Axonics Modulation Technologies

Equipment 1 Model Number

1101

Equipment 1 No. Of Units

120

Equipment 2 Experimental

Yes

Equipment 2 Manufacturer

Axonics Modulation Technologies

Equipment 2 Model Number

1301

Equipment 2 No. Of Units

120

Equipment 3 Experimental

Yes

Equipment 3 Manufacturer

Axonics Modulation Technologies

Equipment 3 Model Number

1401

Equipment 3 No. Of Units

120

Equipment 4 Experimental

Yes

Equipment 4 Manufacturer

Axonics Modulation Technologies

Equipment 4 Model Number

1501

Equipment 4 No. Of Units

120

Equipment 5 Experimental

Yes

Equipment 5 Manufacturer

Axonics Modulation Technologies

Equipment 5 Model Number

1601

Equipment 5 No. Of Units

120

442 application form - Owner and Operator

Will applicant be owner and operator of the station?

Yes

442 application form - Research Project

Is this authorization to be used for providing communications essential to a research project? (The radio communication is not the objective of the research project)? If "YES", include as an exhibit the following information: A description of the nature o

No

442 application form - Station ID

Is the equipment listed in Item 10 capable of station identification pursuant to Section 5.115?

No

Frequencies

Sites

Grant actions

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