Agenda - 01-28-2014 - 2 - Laserfiche WebLink

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Orange County NC Radio Communication Tower and System Infrastructure Upgrade RF Coverage and Sites/Towers COLLOCATION APPLICATION (USA) 10m))) (Tab through the Fields to Enter Info; it at Any Time You Need to UNLOCK the Form to Manually Add Something you (dust Add the "Lock' Icon to your WORD Toolbar to Unprotect Form, NO Password Needed) 5900 Broken Sound Pkwy NW Main Tel: 561 - 995 -7670 / 800- 487 -7483 Boca Raton, FL 33487 Fax: 561 - 226 -3577 Attention: Property Management E-mail: etarkingtonasbasite.com SITE INFORMATION Date: / / SBA Site ID: SBA Site Name: Latitude: ° Longitude: - ° Source of Coordinates: AGL: City: State: TENANT INFORMATION Site ID: Site Name: Company Name: Company Representing: (if consultant) Contact Name: Contact Address: Contact Phone: Contact Fax: ( ) - Contact e-mail: @ LEAS /NI; INFORMATION Contact Name: (1f different) Phone: ( ) - Name of Company to Appear on Lease: state Incorporated: Tax ID #: - Signatory Name: Signatory Title: Corporate Address: Notice Address: With Copies to: Name / Phone & Address to Send Leases For Execution: (if different) # of Original Leases Required (for Tenant only): Special Instructions: CONSTRUCTION INFORMATION Contact Name: Phone: ( ) - Fax: ( ) - E-mail: @ Mobile: ( ) - Projected Installation Date: / ! TENANT 24 !-TOUR EMERGENCY CONTACT NOC Name: I Phone: August 30, 2013 Page 46 of 51 47