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Orange County NC 47 <br /> Radio Communication Tower and System Infrastructure Upgrade <br /> RF Coverage and Sites/Towers <br /> COLLOCATION APPLICATION (USA) SBA t7l <br /> (Tab thrau h the Fields to Enter Into,d at Any Time You Need to UNLOCK the Form to Manual Add Somefin,you Must Add the"Lock"Icon to your WORD Toolbar to Un rated Form,NO Password Needed) <br /> 5900 Broken Sound Pkwy NW Main Tel:561.995-7670 1800-487-7483 <br /> Boca Raton,FL 33487 Fax:561-2263577 <br /> Attention: Property Management E-mail: etarkinatonosbasite.com <br /> SITE INFORMATION <br /> Date: , / SBA Site ID: SBA Site Name: <br /> Latitude: ° " Longitude: - ° ' " Source of Coordinates: <br /> AG L: City: State: <br /> TENANT INFORMATION <br /> Site ID: Site Name: <br /> Company Name: Company Representing: <br /> (if consultant) <br /> Contact Name: Contact Address: <br /> Contact Phone: <br /> Contact Fax:( ) - Contact a-mail: @ <br /> LEASING INFORMATION <br /> Contact Name: Phone:( ) - <br /> (ff different) <br /> Name of Company to Appear on Lease: State Incorporated: Tax ID#: - <br /> Signatory Name: Signatory Title: <br /> Corporate Address: Notice Address: <br /> With Copies to: <br /> Name/Phone&Address to Send Leases For Execution, #of Original Special Instructions: <br /> (ifdifferent) Leases Required <br /> (for Tenant only): <br /> CONSTRUCTION INFORMATION <br /> Contact Name: Phone:( ) <br /> Fax:( ) - E-mail: @ <br /> Mobile:( ) - Projected Installation Date: I I <br /> TENANT 24 HOUR EMERGENCY CONTACT NOG <br /> Name: Phone:( ) <br /> August 30, 2013 Page 46 of 51 ' <br />