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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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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) CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
