Form G Application for an IBN Assignment for a Shared HNI Entity requesting assignment Note: this should be the same name as the legal entity registering radio equipment with a Spectrum Access System (SAS). Confirm with an ✓ the type of entity requesting the IBN: Commercial or authorized agent offering services in the U.S. in the spectrum allocated to CBRS Indicate the radio interface protocol used by the network equipment or end user devices (may choose more than one): LTEOther If other is selected, please list here Evidence of Intent to Provide Service This form provides evidence of intent of the applicant to provide service. Statement of Intent (Fill in name) I, the undersigned, certify that I am authorized to certify I am intending to provide services in the CBRS range utilizing Radio Technologies as noted above. (Fill in name) Authorized Individual Position Today's date Estimated Service Date One of more of sections A or B must be completed. A. GAA - Contract with a SAS Administrator (Y/N) - Select a value -YesNo Note: Email your SAS Administrator documentation to the IMSI-A at IMSIadmin@iconectiv.com. If information is under Non-Disclosure Agreement (NDA), please mark documentation as Confidential and the IMSI-A will treat the documentation accordingly B. PAL FCC License Number *Email a copy of the agreement to the IMSI-A at IMSIadmin@iconectiv.com. If applicant determines that no authorization is required state reason Do special considerations considerations apply? (Y/N) - Select a value -YesNo If YES, please specify the special consideration needed Contact Company Address Room City State Zip Code Phone E-mail Submission of applications via the IMSI Admin website indicates that the applicant: Certifies the accuracy of the information provided in this application. Commits to deploy any assigned IBN with the Shared CBRS HNI within the time period specified by the assignment guidelines. Certifies that the service to be provided adheres to the Assignment Principles (per Section 6 of this document). Certifies that any required authorization has been secured from the appropriate federal, state, or local regulatory bodies, or that such authorization is not required. Acknowledges that it must remit an annual maintenance fee per the IMSI Assignment and Management Guidelines for Shared HNIs for CBRS Range. Understands and agrees that the use of any assigned IMSIs in a manner other than in conformance with the assignment guidelines may result in reclamation of the code(s). Submit Form