Company
Name / Location of Tower Site
Customer ID# (If Applicable)
FCC Tower Registration #
(AGL)Tower Height above ground level
(AMSL) ground elevation level + Tower Height
Tower Coordinates	Latitude
Deg
Minutes
Seconds
	Longitude
Deg
Minutes
Seconds
Manufacturer and model number of the tower light controller?	Flashguard 2000 Flashguard 3000 Flashtech 310 Flashtech 312 Hark Orga TWR Incandescent Other
If other list here
Site telephone number with area code
Name of the nearest public airport (if known)
Non 800 phone number of flight service station (if known)
The name of your representative (who do you want us to contact in the event of a light outage?)
Phone number
Fax
E-Mail
The FAA flight service station is contacted immediately upon detection of a flashing beacon light failure, or power outage lasting more than a (30) minutes. Do you want your representative to be contacted immediately or during regular business hours at the earliest possible time?
The FAA is not required to be notified of sidelight outages. Do you wish your representative to be notified immediately of a sidelight outage, or during regular business hours at the earliest possible time?
If you wish to be notified immediately, please supply any additional numbers to assist in contacting your representative, (home phone number, cell number, pager number).
Questions or comments:

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