NC4FB Mentored Self-Study Program Enrollment
*(Required entry)

*your first name:

*your last name:

your call sign:
(enter if licensed)
*your email address:

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*License exam(s) you will take: (Check all that apply)
Technician
General
Amateur Extra
exam date: (mm/dd/yyyy)
(enter if known)
additional information: (comments, special needs, etc.)