Application Form [pdf]

This document pretains to SES-RWL-20040611-00818 for Renewal on a Satellite Earth Station filing.

IBFS_SESRWL2004061100818_376651

Approved by OMB 3060−0678 FORM 312−R APPLICATION FOR RENEWAL OF RADIO LICENSE IN SPECIFIED SERVICES FOR OFFICIAL USE ONLY APPLICANT INFORMATIONEnter a description of this application to identify it on the main menu: renewal of dometic earth station, receive only 1. Applicant Name: St Marys Hospital Medical Center Phone Number: 608−251−6100 x6714 DBA Name: Fax Number: 608−258−6898 Street: 707 So Mills Street E−Mail: bridget_white@ssmhc.com City: Madison State: WI Country: USA Zipcode: 53715 − 1849 Attention: Bridget White 1

2. Contact Name: Bridget White Phone Number: 608 251 6100 Company: St Marys Hospital Medical Center Fax Number: 608 258 6898 Street: 707 So Mills Street E−Mail: bridget_white@ssmhc.com City: Madison State: WI Country: USA Zipcode: 53715 − 1893 Contact Contract Manager Relationship: Same Title: RENEWAL INFORMATION 3. Rulepart under which this filing is made Rulepart 25 4. Is a fee submitted with this application? If Yes, complete and attach FCC Form 159. If No, indicate reason for fee exemption (see 47 C.F.R.Section 1.1114). Governmental Entity Noncommercial educational licensee Other(please explain): 5. Application is for renewal of license in exact conformity with the existing license as specified below: (a)File Number (b)Date Issued SESRWL1994042901442 1994−06−17 00:00:00.0 (c)Call Sign (d)Location E7237 Madison, WI 2

(e)Nature of Service (f)Class of Station domestic,fixed earth station Receive Only Earth Station (CGO) (g)Expiration Date Petition to reinstate: 2004−06−17 00:00:00.0 6. Note any changes such as discontinuance of use of a frequency, or of a type of emission or of a transmitter which have been made since the last application covering this station was filed: Items 7(a) and (b) apply to Part 21 licenses only. 7(a) Has there been removal of equipment or alteration of facilities as to render the Station not operational? Yes No N/A If YES when: (b) If this is a Multipoint Distribution Service (MDS) station, is there a ownership interest in control by, affiliation Yes with, or leasing arrangement with a cable television company? No N/A 8. Applicant represents that there has been no change in applicant’s organization and that there has been no transfer of control or changes in the applicant’s relation to the station, or financial responsibility; that applicants most recent application or report embodying this information, as identified below, is to be considered as a part of this application, and the truth of the statements therein contained is hereby reaffirmed. Note here any further exceptions, not already covered in question 6 or 7. File Number SESRWL1994042901442 Date 06/17/1994 3

9. Would a Commision grant of this application come within 47 CFR 1.1307, such that it may have a significant environmental Yes impact? No N/A If YES, attach as an Exhibit an Environmental Assessment required by 47 CFR 1.1311: If NO, Explain briefly why not: 10. Certification: The applicant certifies that, in the case of an individual applicant, he or she is not subject to a denial of federal Yes benefits pursuant to section 5301 of Anti−Drug Abuse Act of 1988, 21 U.S.C. 853a, or, in the case of a nonindividual applicant (e. No g., corporation, partnership or other unincorporated association), no party to the application is subject to denial of federal benefits pusuant to that section. For the definition of a "party" for these purposes, see 47 CFR 1.2002(b). a. Applicant waives any claim to the use of any particular frequency or of the electromagnetic spectrum as against the regulatory power of the United States because of the previous use of the same, whether by license or otherwise, and requests a station license in accordance with this application. Applicant acknowledges that all attached exhibits are a material part hereof. b. The undersigned, individually and for the applicant, hereby certifies that the statements made in this application are true, complete and correct to the best of the signer’s knowledge and belief, and are made in good faith. 11. Designate Appropriate Classification: Individual Unincorporated Association Partnership Corporation Governmental Entity Other (please specify) Hospital, non−profit entity 4

12. Please supply any need attachments. 1: 2: 3: CERTIFICATION 13. Typed Name of Person Signing 14. Title of Person Signing Bridget White Contract Manager WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND / ORIMPRISONMENT (U.S. Code, Title 18, Section1001), AND/OR REVOCATION OF ANY STATIONAUTHORIZATION (U.S. Code, Title 47, Section312(a)(1)), AND/OR FORFEITURE (U.S. Code,Title 47, Section 503). FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT The public reporting for this collection of information is estimated to average 2.25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD−PERM, Paperwork Reduction Project (3060−0678), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to jboley@fcc.gov. PLEASE DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. Remember − You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060−0678. THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104−13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507. 5


Document Created: 2019-05-30 09:00:28
Document Modified: 2019-05-30 09:00:28
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