Licence Application 1a) Are you an existing Ofcom customer? YesNo 1b) If yes, what is your customer reference? (can be found at the top-right of your licence document) 2a) Please select one of the following: Individual or Sole TraderPartnershipPublic Limited CompanyLimited CompanyIncorporated AssociationUnincorporated AssociationGovernmentCrown BodyPublic BodyLocal GovernmentRegistered CharityUniversity/EducationalNon UK CompanyNon UK Govt/AdministrationReligious BodyNHS England & WalesNHS ScotlandNHS Northern Ireland 2b) I) Company Registration Number (if applicable) 2b) II) Number of partnership members (if applicable) 2b) III) Charity Registration Number (if applicable) 3) Licensee Name and Address (This should be the licensee head office) Organisation Name: Trading Name (if applicable): Address Line 1: Address Line 1: Postal Town: Postcode: Country: Telephone No.: Fax No.: Email Address: 3b) Licence Contact Name and Address (This is usually the person who will be using/applying for the licence, person in charge of radio system or person responsible onsite where radios are used) (If address is same as above please leave blank) Forename: Surname: Address Line 1: Address Line 1: Postal Town: Postcode: Country: Telephone No.: Fax No.: Email Address: 3c) Renewal Payments Contact Name and Address (This is usually the person that will be responsible for paying licence renewals etc. Apex will pay for the initialapplication on your behalf. Quite often this is the sameas licence contact. Apex can also handle renewals onyour behalf -see section. (If address is same as above please leave blank) Forename: Surname: Address Line 1: Address Line 1: Postal Town: Postcode: Country: Telephone No.: Fax No.: Email Address: Additional Comments: 4) Declaration By placing an 'X' in the box to the right I confirm that: a) The information given in this application form is accurate and correct to the best of my knowledge. b) The licensee consents to receive notice of variations or changes of the product Terms and Conditions and other communications regarding their licence by email. c) I understand and agree that the information provided in this form will be used by Ofcom for the purpose of issuing, amending, validating and/or surrendering a Business Radio licence and, if applicable, published on the Wireless Telegraphy Act Register. d) This information may also be provided by Ofcom to law enforcement agencies (such as the police and other third parties) for crime and taxation purposes and the discharging of functions relating to regulatory activities. Declaration conditions:AgreeDisagree Name of person completing form: Company: