Your Full Name *
E-Mail *
Phone Number: *
Street Address
City
State
Zip Code
Do you listen to the Station at least twice a month? yes No
How long have you been a listener of the Station?
Are you experiencing interference when tuning into the Station? Yes No
If possible, please identify the source of the interference (for example, by identification of the interfering station’s call sign, type of programming, etc’):
Are you experiencing interference to reception of the Station while at home? Yes No
If yes, please give your home location with as much specificity as possible:
Please specify the audio equipment (make, model, serial number) on which you are attempting to listen the Station at home:
Are you experiencing interference to reception of the Station while at work? Yes No
If yes, please give your work location with as much specificity as possible:
Please specify the audio equipment (make, model, serial number) on which you are attempting to listen to the Station at work:
Are you experiencing interference to the reception of the Station while driving? Yes No
If yes, please give the location(s) where you are experiencing interference to reception of the Station while driving.
Please specify the audio equipment (make, model, serial number) on which you are attempting to listen to the Station while driving:
Do you have any personal, legal, employment, financial, family or business connection of any kind with the Station, its owners, management, or employees? If so, please explain:
Do you understand that your complaint may be submitted to the Federal Communications Commission? Yes No
Are you willing to be contacted and work with representatives of the interfering station to resolve the problems you are experiencing with reception of the Station? (Your cooperation is not required by FCC policy.) Yes No
Do you have any additional comments to share with us at this time regarding the interference?ms you are experiencing with reception of the Station? (Your cooperation is not required by FCC policy.)
Your Name again, Please
Date
