Bi-Directional Amplifier (BDA) Installation Notification Form

Retransmission Authorization Request - BDA Installation Notification Form
Building Owner *
Building Name - if different from above
Building Address*
County*
Location of Equipment in Building - be very specific*
ex: bldg 1, lower level, west hall ; ex 2: 3rd floor sw corner above white cabinet
Installer Contact Information: Name
Installer Contact Information: Phone and Email Address
Equipment Owner Contact Information: Name *
Equipment Owner Contact Information: Phone AND Email Address*
BDA Manufacturer
BDA Model
BDA Type
ex: A or B
For Type "A" above, please identify sites you plan to connect to:
ex: Montgomery County Simulcast, Fayette
Antenna Style
ex: Yagi or Omni Directional
Antenna Gain (dBd)
ex:
ERP of BDA Donor Antenna (-50 to +37)
ex:
Antenna Coordinates Latitude
ex: WGS84 format 41.5868N
Antenna Coordinates Longitude
ex: WGS84 format -93.598022W
Antenna Height above ground of outdoor antenna (ft)
ex:
Antenna Height above Mean Sea Level of outdoor antenna (amsl) (ft)
ex:
Signal Level at Donor Site (-95 to -75 dBm)
ex:
Antenna azimuth (degrees true)
ex:
Licenses call letters to be rebroadcast - list all
Notes - further explanation for this device
Do you have a signed Retransmission Authorization Agreement from the license holder for licenses to be rebroadcast?

YesNo
I hereby request retransmit authorization via BDA for in-building public safety radio system coverage according to the information provided.

First NameLast Name
If at any time during or after installation, the BDA system negatively impacts the ISICS network, the building owner will be required to immediately turn off the malfunctioning BDA system until correct functioning is restored.

Questions can be directed to:

ATTN: ISICS Frequency License Holder @

ISICSNOC@DPS.STATE.IA.US
Should be Empty:

Retransmission Authorization Request - BDA Installation Notification Form