1. TL/01
-١-
‫اﻟﺜﺎﻟﺜﺔ‬ ‫اﻟﻔﺌﺔ‬ ‫ﻣﻦ‬ ‫إﺗﺼﺎﻻت‬ ‫ﺗﺮﺧﻴﺺ‬ ‫ﻃﻠﺐ‬‫اﻟﺜﺎﻟﺜﺔ‬ ‫اﻟﻔﺌﺔ‬ ‫ﻣﻦ‬ ‫إﺗﺼﺎﻻت‬ ‫ﺗﺮﺧﻴﺺ‬ ‫ﻃﻠﺐ‬<<
AApppplliiccaattiioonn ffoorr CCllaassss IIIIII TTeelleeccoommmmuunniiccaattiioonnss LLiicceennssee
Name of Applicant : ……………………..…………………………………………….…………… ‫اﻟﻄﻠﺐ‬ ‫ﻣﻘﺪم‬:
Nationality: ……………………..…………………………………………….…………… ‫اﻟﺠﻨﺴﻴﺔ‬:
Address
(Physical Location):
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫اﻟﻌﻨﻮان‬
)‫اﻟﻤﺆﺳﺴﺔ‬ ‫ﻣﻘﺮ‬/‫اﻟﺸﺮآﺔ‬(:
P.O. Box :
Postal code:
City:
Country:
……………………..…………………………………………….……………
……………………..…………………………………………….……………
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫اﻟﺒﺮﻳﺪ‬ ‫ﺻﻨﺪوق‬:
‫اﻟﺒﺮﻳﺪي‬ ‫اﻟﺮﻣﺰ‬:
‫اﻟﻤﺪﻳﻨﺔ‬:
‫اﻟﺪوﻟﺔ‬:
Telephone Number :
Fax Number :
E-mail :
……………………..…………………………………………….……………
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫اﻟﻬﺎﺗﻒ‬ ‫رﻗﻢ‬:
‫اﻟﻔﺎآﺲ‬ ‫رﻗﻢ‬:
‫اﻻﻟﻜﺘﺮوﻧﻲ‬ ‫اﻟﺒﺮﻳﺪ‬:
Commercial
Registration Number : ……………………..…………………………………………….…………… ‫اﻟﺘﺠﺎري‬ ‫اﻟﺴﺠﻞ‬ ‫رﻗﻢ‬:
Telecommunications
activities in which the
applicant is engaged
……………………..…………………………………………….……………
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫اﻟﺘﻲ‬ ‫اﻻﺗﺼﺎﻻت‬ ‫أﻧﺸﻄﺔ‬
‫اﻟﻤﺘﻘﺪم‬ ‫ﻳﺰاوﻟﻬﺎ‬:
CEO/GM Name :
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫اﻟﻤﺪﻳﺮ‬ ‫أﺳﻢ‬
‫اﻟﺘﻨﻔﻴﺬي‬/‫اﻟﻌﺎم‬ ‫اﻟﻤﺪﻳﺮ‬:
Names of the
authorized
signatories:
……………………..…………………………………………….……………
……………………..…………………………………………….……………
‫ﺑﺎﻟﺘﻮﻗﻴﻊ‬ ‫اﻟﻤﺨﻮﻟﻴﻦ‬ ‫أﺳﻤﺎء‬
Contact persons :
١-‫اﻟﻬﺎﺗﻒ‬Tel: …………………………….…………………………………:
‫اﻻﻟﻜﺘﺮوﻧﻲ‬ ‫اﻟﺒﺮﻳﺪ‬:.......………...……….……………....................………:E-mail
٢-‫اﻟﻬﺎﺗﻒ‬Tel: ………………………………………….……………………:
‫اﻻﻟﻜﺘﺮوﻧﻲ‬ ‫اﻟﺒﺮﻳﺪ‬:........……..……….……………………………………:E-mail
‫اﻟﺬﻳﻦ‬ ‫اﻷﺷﺨﺎص‬ ‫أﺳﻤﺎء‬
‫ﻋﻨﺪ‬ ‫ﺑﻬﻢ‬ ‫اﻻﺗﺼﺎل‬ ‫ﻳﻤﻜﻦ‬
‫اﻟﺤﺎﺟﺔ‬:

2. TL/01
-٢-
‫ﻣﻦ‬ ‫ﻷآﺜﺮ‬ ‫اﻟﻤﺎﻟﻜﻴﻦ‬ ‫اﻟﻤﺴﺎهﻤﻴﻦ‬ ‫آﺒﺎر‬١٠%‫اﻟﻤﺎل‬ ‫رأس‬ ‫ﻣﻦ‬
Applicant’s controlling parties/ shareholders owning more than 10% of the Capital
‫اﻟﻤﺴﺎهﻤﻴﻦ‬ ‫آﺒﺎر‬ ‫أﺳﻤﺎء‬
Controlling
Party/Shareholder’s
Name
‫اﻟﻤﻤﻠﻮآﺔ‬ ‫اﻷﺳﻬﻢ‬ ‫ﻧﺴﺒﺔ‬
Percentage of shares
owned
‫اﻟﻬﺎﺗﻒ‬ ‫رﻗﻢ‬
Phone Number
‫اﻟﻌﻨﻮان‬
Address
‫ﺗﻘﺪﻳﻤﻬﺎ‬ ‫اﻟﻤﻘﺘﺮح‬ ‫اﻟﺨﺪﻣﺎت‬
Description of the
proposed Service
……………………..……………………………...…………………………………….……………
……………………..……………………………...…………………………………….……………
……………………..……………………………...…………………………………….……………
‫ﺑﺎﻟﺨﺪﻣﺎت‬ ‫اﻟﻤﺴﺘﻬﺪﻓﺔ‬ ‫اﻟﻤﻨﺎﻃﻖ‬
Targeted areas of service
……………………..……………………………...…………………………………….……………
……………………..……………………………...…………………………………….……………
……………………..……………………………...…………………………………….……………
‫ﺑﻄ‬ ‫ﺗﻘﺪﻣﺖ‬ ‫هﻞ‬‫ﺳﺎﺑﻘﺎ؟‬ ‫اﺗﺼﺎﻻت‬ ‫ﺗﺮﺧﻴﺺ‬ ‫ﻠﺐ‬....................
‫ﻋﻠﻴﻪ؟‬ ‫اﻟﻤﻮاﻓﻘﺔ‬ ‫ﺗﻤﺖ‬ ‫هﻞ‬.......................................،‫آﺎﻧﺖ‬ ‫إذا‬‫اﻹﺟﺎﺑﺔ‬‫اﻟﺒﻨﺪ‬ ‫ﻋﻠﻰ‬ ‫اﻹﻃﻼع‬ ‫ﻳﺮﺟﻰ‬ ‫ﺑﻨﻌﻢ‬‫اﻟﺘﺎﻟﻲ‬.
‫آﺎﻧﺖ‬ ‫وإذا‬‫اﻹﺟﺎﺑﺔ‬‫ﺑ‬‫ـ‬‫ﻼ‬,‫ﻳﺮﺟﻰ‬‫اﻟﺮﻓﺾ‬ ‫أﺳﺒﺎب‬ ‫ﺗﻮﺿﻴﺢ‬.
.……………………………………………………………………………………………...................................................................
……………………………………………………………………………………………....................................................................
……………………………………………………………………………………………....................................................................
Did the applicant apply for a telecommunication license before? …………………….
Was the application successful? .................................. If yes please refer to the following clause.
If no, please provide reasons for application refusal
.…………………………………………………………………………………………….....................................................................
……………………………………………………………………………………………......................................................................
……………………………………………………………………………………………......................................................................
‫اﻟﺘﺠﺎري‬ ‫واﻻﺳﻢ‬ ‫اﻟﻨﻮع‬)‫ﻳﺨﺘﻠﻔﺎن‬ ‫آﺎﻧﺎ‬ ‫إن‬(‫ﺳﺎﺑﻘﺎ‬ ‫واﻟﻤﻘﺪﻣﺔ‬ ‫اﻟﻤﺮﺧﺼﺔ‬ ‫اﻻﺗﺼﺎﻻت‬ ‫ﻟﺨﺪﻣﺎت‬/‫اﻟﻄﻠﺐ‬ ‫ﻣﻘﺪم‬ ‫ﻗﺒﻞ‬ ‫ﻣﻦ‬ ‫ﺣﺎﻟﻴﺎ‬ ‫اﻟﻤﻮﻓﺮة‬
Types and brand names (if different) of telecommunication licensed services provided previously/ are provided by the applicant.
‫اﻟﺘﺮﺧﻴﺺ‬ ‫ﻓﺌﺔ‬
‫اﻟﺘﺠﺎري‬ ‫واﻻﺳﻢ‬
Class of
License and
brand name
‫اﻟﺘﺮﺧﻴﺺ‬ ‫ﻧﻮع‬
Type of
License
‫اﻹﺻﺪار‬ ‫ﺗﺎرﻳﺦ‬
Date of issuance
‫اﻻﻧﺘﻬﺎء‬ ‫ﺗﺎرﻳﺦ‬
Date of expiry
‫ﻟﻠﺘﺮﺧﻴﺺ‬ ‫اﻟﺤﺎﻟﻲ‬ ‫اﻟﻮﺿﻊ‬
Current status of the
license
‫اﻟﻤﻼﺣﻈﺎت‬
Remarks

3. TL/01
-٣-
For Bank Use: :‫اﻟﺒﻨﻚ‬ ‫ﻹﺳﺘﺨﺪام‬
‫إﻗﺮار‬
Declaration
•‫أﻧﺎ‬/‫إﺧﻔﺎء‬ ‫ﻳﺘﻢ‬ ‫وﻟﻢ‬ ‫ﺻﺤﻴﺤﺔ‬ ‫اﻟﺴﺎﺑﻘﺔ‬ ‫اﻟﻤﻌﻠﻮﻣﺎت‬ ‫ﺑﺄن‬ ‫رﺳﻤﻴﺎ‬ ‫ﻧﻌﻠﻦ‬ ‫ﻧﺤﻦ‬‫ﺷ‬ ‫أي‬‫ﺊ‬.
•‫أﻧﺎ‬/‫ﺎدر‬‫اﻟﺼ‬ ‫ﺎﻻت‬‫اﻻﺗﺼ‬ ‫ﻴﻢ‬‫ﺗﻨﻈ‬ ‫ﺎﻧﻮن‬‫ﺑﻘ‬ ‫ﺰام‬‫واﻻﻟﺘ‬ ‫ﺪ‬‫ﺑﺎﻟﺘﻘﻴ‬ ‫ﻧﺘﻌﻬﺪ‬ ‫ﻧﺤﻦ‬‫ﻠﻄﺎﻧﻲ‬‫اﻟﺴ‬ ‫ﻮم‬‫ﺑﺎﻟﻤﺮﺳ‬٣٠/٢٠٠٢،‫ﺪ‬‫واﻟﻘﻮاﻋ‬‫ﺎت‬‫واﻟﺘﻌﻠﻴﻤ‬
‫اﻟﻬﻴﺌﺔ‬ ‫ﻣﻦ‬ ‫ﺗﺼﺪر‬ ‫ﻗﺮارات‬ ‫وأﻳﺔ‬.
•‫أﻧﺎ‬/‫ﺑﻘﺒﻮل‬ ‫ﻧﻠﺘﺰم‬ ‫ﻧﺤﻦ‬‫ﺗﺮﺧﻴﺺ‬ ‫ﻋﻠﻰ‬ ‫اﻟﺤﺼﻮل‬ ‫ﻃﻠﺐ‬ ‫ﺑﺘﻘﺪﻳﻢ‬ ‫اﻟﺨﺎﺻﺔ‬ ‫واﻹﺟﺮاءات‬ ‫اﻟﻘﻮاﻋﺪ‬‫ﻣﻦ‬‫اﻟﺜﺎ‬ ‫اﻟﻔﺌﺔ‬‫ﻟﺜﺔ‬،‫وإرﻓﺎق‬‫اﻟﻤﺴﺘﻨﺪات‬
‫ﻣﻊ‬ ‫اﻟﻤﻄﻠﻮﺑﺔ‬‫ﻣﻌﻠﻮﻣﺎت‬ ‫أﻳﺔ‬ ‫ﻟﺘﻘﺪﻳﻢ‬ ‫اﻻﺳﺘﻌﺪاد‬‫إﺿﺎﻓﻴﺔ‬‫اﻟﺤﺎﺟﺔ‬ ‫ﻋﻨﺪ‬ ‫وﺛﺎﺋﻖ‬ ‫أو‬.
• I/We hereby solemnly declare that the foregoing facts are true and correct and nothing has been
concealed.
• I/We also undertake to observe and abide by Telecommunications Regulatory Act issued under the
Royal Decree No. 30/2002, Telecommunications Rules and Regulations and any decisions issued by
TRA.
• I/We also declare acceptance of the rules and procedures for Class III Telecommunications Licenses
Application and have enclosed all relevant documents applicable and willing to provide any further
information and documents as needed.
Name of applicant's
authorized representative:
.............................................................................................................................
.............................................................................................................................
‫ﻣﻘﺪم‬ ‫ﺑﺘﻤﺜﻴﻞ‬ ‫اﻟﻤﺨﻮل‬
‫اﻟﻄﻠﺐ‬:
Position: ............................................................................................................................. ‫ﻣﻬﻨﺘﻪ‬:
Date : ............................................................................................................................. ‫اﻟﺘﺎرﻳﺦ‬:
Signature & Stamp :
.............................................................................................................................
‫اﻟﺘﻮﻗﻴﻊ‬‫واﻟﺨﺘﻢ‬:
‫اﻟﻤﺒﻠﻎ‬
Amount
‫اﻟﺒﻨﻚ‬ ‫ﺧﺘﻢ‬
Bank Stamp
‫اﻟﺘﻮﻗﻴﻊ‬
Signature ‫وﻗﺪرﻩ‬ ‫ﻣﺒﻠﻎ‬ ‫إﻳﺪاع‬ ‫ﻳﺠﺐ‬)٥٠٠(‫ر‬.‫ع‬‫ﻓﻲ‬
‫ﺣﺴﺎب‬‫ﺑﺎﻟﺒﻨﻚ‬ ‫اﻟﻬﻴﺌﺔ‬.
‫رﻗﻢ‬ ‫ﺣﺴﺎب‬:٠٠٨١٠١٦-٥٠٠٠٩-٠٠٢٦
‫ﻣﺴﻘﻂ‬ ‫ﺑﻨﻚ‬-‫ﺣﻄﺎط‬ ‫ﺑﻴﺖ‬ ‫ﻓﺮع‬
Payment of Omani Riyal (R.O. 500)
should be deposited in TRA Bank
Account.
Account No.0026 - 50009- 0081016
Bank Muscat-Hatat House Branch.