Form G

Application for an IBN Assignment for a Shared HNI

Note: this should be the same name as the legal entity registering radio equipment with a Spectrum Access System (SAS).

Commercial or authorized agent offering services in the U.S. in the spectrum allocated to CBRS




Evidence of Intent to Provide Service
This form provides evidence of intent of the applicant to provide service.

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)




One or more of sections A or B must be completed.*


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

*Email a copy of the agreement to the IMSI-A at IMSIadmin@iconectiv.com.



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).