Prefer to fill out the application offline? Download printable version here. Step 1 of 2 50% Customer InformationCompany Name*Entity Type (i.e. Inc., LLP)*State of Inc.*Phone*FaxService (PCS, SMR)*Customer AddressesCompany Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Notice Address 1 Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Notice Address 2 Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Customer ContactsPrimary ContactName First Last TitlePhoneEmail SignatoryName First Last TitlePhoneEmail Emergency ContactName First Last TitlePhoneEmail Techincal/OpsName First Last TitlePhoneEmail RF EngineerName First Last TitlePhoneEmail Billing ContactName First Last TitlePhoneEmail Legal ContactName First Last TitlePhoneEmail Site InformationCustomer Site Number/NameInSite Site Number/NameSite LatitudeSite LongitudeSite Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Structure TypeUse This Section to Provide a Description of Collocation or Modification RequestUse This Section to List Equipment to Be RemovedApplication Prepared ByName First Last CompanyTitlePhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email Please be sure to fill in all applicable fields such that it represents your FINAL equipment loading once installation is complete. The mounting method and exact location of the space and equipment listed herein shall be subject to InSite's approval. Site Name and NumberLicensee Name First Last System RequirementsPower Provided ByTELCO Provided ByPower RequirementsAmpsVoltsNumber of OutletsGenerator InformationGenerator Provided ByMakeModelFuel TypeCapacity (in gallons)Battery InformationQuantityMakeModelSpace Requirement & Radio InventorySpace RequiredGround SpaceFloor SpaceTotal Square FeetDimensions of Equipment Floor/Ground SpaceEquipment Height (in inches)Dimensions of Generator Ground SpaceDimensions of Fuel Tank Ground SpaceTransmitter InformationNo. of Transmitters (Tx)Transmitter Make/ModelTransmitter Power Output (in watts)Reciever InformationNo. of Receivers (Rx)Receiver Make/ModelTransmitter ERP (in watts)Shelter/Cabinet also containsEquipment Loading Description (Final Configuration)Antenna TypeAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) # of Antennas/SectorAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Tx, Rx or BothAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Antenna ManufacturerAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Antenna ModelAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Antenna Dimensionsin inchesAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Antenna Weightin poundsAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Antenna Rad CtrPlease Indicate Antenna: Center - on tower in Feer Orientation - N, S, E, W Azimuths - in DegreesAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) # of TMAs/ SectorTower Mounted Amplifier (TMA) Tower Top Amplifer (TTA)Antenna 1Antenna 2Antenna 3 TMA ManufacturerAntenna 1Antenna 2Antenna 3 TMA ModelAntenna 1Antenna 2Antenna 3 TMA Dimensionsin inchesAntenna 1Antenna 2Antenna 3 TMA Weightin poundsAntenna 1Antenna 2Antenna 3 TMA Rad Ctrin feetAntenna 1Antenna 2Antenna 3 OtherAntenna 1Antenna 2Antenna 3 OtherAntenna 1Antenna 2Antenna 3 OtherAntenna 1Antenna 2Antenna 3 OtherAntenna 1Antenna 2Antenna 3 OtherAntenna 1Antenna 2Antenna 3 Transmit FrequenciesReceive Frequencies# of Lines/SectorAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Line SizeAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) # of Lines/SectorAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Line SizeAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Mount TypeAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) Mount SizeAntenna 1Antenna 2Antenna 3DISH(ES)DISH(ES) CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
