FCC Form 2100, Sch FM Booster Program Origination Notification

FOR

FCC

USE

ONLY

Federal Communications Commission Not Yet Approved by OMB

Washington, DC 20554 3060-XXXX

Estimated Time Per Response: 1 hour

FCC FORM 2100, SCHEDULE 336

FOR COMMISSION USE ONLY

FILE NO.

FM BOOSTER PROGRAM ORIGINATION

NOTIFICATION

SECTION I – GENERAL INFORMATION

1.

Legal Name of the Applicant

Mailing Address

City State or Country (if foreign address) ZIP Code

Telephone Number (include area code) E-Mail Address

FCC Registration Number Call Sign of FM Booster Station Facility ID Number of FM Booster Station

Call Sign of FM or LPFM Primary Station Facility ID Number of FM or LPFM Primary Station

2.

Contact Representative (if other than licensee/permittee) Firm or Company Name

Mailing Address

City State or Country (if foreign address) ZIP Code

Telephone Number (include area code) E-Mail Address

3. Community of License of FM Booster Station: ___________________________________________ State: ____________

4. This serves as notification of commencement or termination of FM booster program origination

on: ______________________________ (mm/dd/yyyy)

(If giving notification of program origination commencement, continue to Item 5 and complete all items. If giving notice of program origination termination, skip to Item 9 and complete Item 9 and the Certification.)

5. In the event of interference, questions should be directed to licensee’s technical representative:

Name	Telephone Number (include area code, omit dashes)

6. Licensee certifies that the program-originating FM booster station complies with all Emergency Alert System

(EAS) requirements in Part 11 of the Commission’s rules (47 CFR §§ 11.1 – 11.61). Yes No

7. Licensee certifies that the program-originating FM booster station will originate programming for no more than

three (3) minutes of each broadcast hour. Yes No

8. Licensee certifies that the program-originating FM booster station minimizes interference to its primary station

through synchronization or terrain shielding. Yes No

9. Anti-Drug Abuse Act Certification. Licensee certifies that neither licensee nor any party to the application is

subject to denial of federal benefits pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. Yes No

§ 862.

FCC Form 2100 Schedule 336 (Page 1) FCC Form 2100 Schedule 336

Draft – January 2025

CERTIFICATION

I hereby certify that the statements in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I acknowledge that all certifications and attached Exhibits are considered material representations.

Typed or Printed Name of Person Signing	Typed or Printed Title of Person Signing
Signature	Date

WILLFUL FALSE STATEMENTS 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).

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take on average 1 hour. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this burden estimate, or on how we can improve the collection and reduce the burden it causes you, please e-mail them to pra@fcc.gov or send them to the Federal Communications Commission, OMD-PPM (3060-XXXX), Washington, DC 20554. Please DO NOT SEND COMPLETED APPLICATIONS 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 of if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-XXXX.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L.104-13, OCTOBER 1, 1995, 44 U.S.C. 3507.

FCC Form 2100 Schedule 336 (Page 2) FCC Form 2100 Schedule 336

Draft – January 2025