Field Name · Applicant
Italic names are derived; accent values differ from the applicant’s prior license.
| Applicant Type | I - Individual |
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| Entity Type | L - Licensee or Assignee |
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| Entity Name | FORM, FREDRIC A |
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| Attention | |
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| First Name / Middle Init / Last Name / Name Suffix | FREDRIC A FORM |
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| Street Address | 3751 JULES LN |
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| Po Box | |
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| Locality | WANTAGH |
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| County | Nassau County |
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| State | NY - New York |
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| Postal Code | 11793 |
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| Zip Location | 40°39'04.6"N 73°30'53.0"W |
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| Maidenhead | FN30fp |
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| FRN | 0003549136 |
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| Geo Region | 2 / NY |
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| Licensee ID/SGIN | L00046496 / 000 |
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| Callsign | KA2VQK |
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| Last Action Date | 2003-10-28 |
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| Radio Service | HA - Amateur |
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| App Purpose | RO - Renewal Only |
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| App Source | B - Batch |
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| App Status | G - Granted |
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| Entered Timestamp | 2003-10-28 |
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| Fee Control Num | |
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| Orig Purpose | RO - Renewal Only |
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| Receipt Date | Tue 2003-10-28 |
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| Payment Date | |
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| Is From Vec | |
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| Is Trustee | |
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| Operator Group | D - 2x3 |
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| Licensee Class | T - Technician |
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| New Seq Callsign | |
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| Trustee Callsign | |
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| Trustee Name | |
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| ULS Group / ULS Region | D / 2 |
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| Prev Callsign / Prev Class | |
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| Vanity Relationship | |
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| Vanity Type | |
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| Fee Exempt / Waiver | N / N |
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