COLLOCATION APPLICATION

Type of Application New Lease Amendment

Date

NCN SITE INFORMATION

NCN Site Name

NCN Site Number

NCN Site Address

Latitude

Longitude

Type
---BuildingCasinoLight PoleOtherShopping MallSign PoleSports Venue

CARRIER INFORMATION

Carrier Site Name

Carrier Site Number

Carrier Legal Entity Name

State of Registration

Type of Entity
---LLCCorpGen PartOtherS CorpSole Prop

Carrier NOC

Notice Address

Copy to

Signatory Name

Signatory Title

Leasing Contact

Leasing Contact Number

Leasing Email

Construction Contact

Construction Contact Number

Construction Email

FREQUENCY INFORMATION

TX

RX

Licensed
Yes

Unlicensed
Yes

Technology Type
---3G4GCMDALTEMWOTHERTVWIFI

Antenna Gain

EIRP

TX Power Output

Electrical Service Required

Power Type
---AC/DCAmpsVoltsWatts

GROUND/ROOFTOP/INTERIOR LEASED RIGHTS

Total Area Dimensions

Total SF

Ground
Yes

Rooftop
Yes

Interior
Yes

Pad Dimensions Width

Pad Dimensions Height

Cabinet Dimensions Width

Cabinet Dimensions Height

Shelter Dimensions Width

Shelter Dimensions Height

CabinetShelter Weight

Number of batteries

Model of Batteries

Generator Yes
Yes

Generator No
Yes

Fuel Type
---DieselNatural GasOtherPropane

Size

Pad Width

Pad Height

EQUIPMENT LEASED RIGHTS

CABLE/FIBER/COAX LEASED RIGHTS

GENERAL SCOPE OF WORK, SPECIAL CONSIDERATIONS AND COMMENTS

GENERAL SCOPE OF WORK SPECIAL CONSIDERATIONS AND COMMENTSRow1