Small Cell Site License Form A-1

APPLICATION FOR SMALL CELL SITE LICENSE

Please Review the PMLP Technical and Aesthetic Small Cell Standards Packet and Site License Application Packet before filling out the form below.

Owner/Carrier: *

Street Adress: *

City, State, And Zip: *

Date: *

Entity (Licensee) Responsible for WCF Installation. Control, and Maintenance (if different from above)

Street Address:

City and State:

Date:

In Accordance with terms and conditions of the License Agreement between the parties, dated Date application is hereby made for license to make WCF attachments to JO poles and WCF Attachments to SO poles. A completed Form A-2 will be submitted by mail with the complete application package. This will acknowledge submittal of all of the necessary information to comply with the License Agreement and the requirements of this "Application Form for the Small Cell Site Licenses" packet.

Licensee's Name (print): *

Licensee's Signature: *

Clear

Title: *

Tel. No.: *

E-mail Address: *