Application Form [pdf]

This document pretains to SES-STA-INTR2018-02656 for Special Temporal Authority on a Satellite Earth Station filing.

IBFS_SESSTAINTR201802656_1424000

Approved by OMB 3060−0678 APPLICATION FOR EARTH STATION SPECIAL TEMPORARY AUTHORITY APPLICANT INFORMATIONEnter a description of this application to identify it on the main menu: STA for .98 Meter Antenna 1. Applicant Name: WALGREEN CO. Phone Number: 224−542−6880 DBA Name: Fax Number: Street: 1084 MOUNT PROSPECT E−Mail: fred.pino@walgreens.com PLAZA City: MT PROSPECT State: IL Country: USA Zipcode: 60056 − Attention: FRED PINO 1

2. Contact Name: FRED PINO Phone Number: 224−542−6880 Company: WALGREEN CO. Fax Number: Street: 1084 MOUNT PROSPECT E−Mail: fred.pino@walgreens.com PLAZA City: MT PROSPECT State: IL Country: USA Zipcode: 60056 − Attention: Relationship: Same (If your application is related to an application filed with the Commission, enter either the file number or the IB Submission ID of the related application. Please enter only one.) 3. Reference File Number or Submission ID IB2018002655 4a. 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): 4b. Fee Classification CGV − Fixed Satellite VSAT System 5. Type Request Use Prior to Grant Change Station Location Other 6. Requested Use Prior Date 06/21/2018 2

7. CityMT PROSPECT 8. Latitude (dd mm ss.s h) 42 4 8.0 N 9. State IL 10. Longitude (dd mm ss.s h) 87 55 6.0 W 11. Please supply any need attachments. Attachment 1: EXHIBIT A Attachment 2: EXHIBIT B Attachment 3: 12. Description. (If the complete description does not appear in this box, please go to the end of the form to view it in its entirety.) SEE ATTACHED EXHIBITS 13. By checking Yes, the undersigned certifies that neither applicant nor any other party to the application is Yes No subject to a denial of Federal benefits that includes FCC benefits pursuant to Section 5301 of the Anti−Drug Act of 1988, 21 U.S.C. Section 862, because of a conviction for possession or distribution of a controlled substance. See 47 CFR 1.2002(b) for the meaning of "party to the application" for these purposes. 14. Name of Person Signing 15. Title of Person Signing Fred Pino Technical Architect 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 AUTHORIZATION (U.S. Code, Title 47, Section 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503). 3

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT The public reporting for this collection of information is estimated to average 2 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 PRA@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. 4


Document Created: 2019-04-25 04:11:58
Document Modified: 2019-04-25 04:11:58
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