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Ground Station Interference Form

Submitter's Information

Name
Name
First
Last

Administrative Information

Contact Name
Contact Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Description & Location of System Affected

Transmitter Address
Transmitter Address
City
State/Province
Zip/Postal
(Bldg #, Room #, etc)
(e.g., On roof above gate C10)

Interference Description

(Constant, Intermittent, Sporadic, etc)
(Voice, Data Bursts, Squeals, etc)