Form A Entity requesting assignment Select the type of entity requesting the HNI (select one) - Select a value -Public Network Operator (commercial or government, or its authorized agent) offering mobility services in the U.S. with a need to roam onto/from commercial networksProvider of a service profile management system (e.g., HLR, Home AAA) based in the U.S. for end user devices that can access public networks in the U.S. Indicate the radio interface protocol used by the network equipment or end user devices (may choose more than one) - None -GPRSEDGEW-CDMAHSPA1xRTTHRPD/EVDOLTE/LTE Advanced5G Provide Evidence of authorization, if required, from the appropriate federal, state or local authority Wireless license number. Email a copy of the license to the IMSI-A at IMSIadmin@iconectiv.com Date of issuance: If applicant determines that no authorization is required, State reason Is this request associated with a request for multiple mobile network codes (MNCs), per Section 8.4.3? - Select a value -YesNo If YES, please list the other wireless licenses associated with this request Do special considerations apply, per section 8.4.2 or an addendum? - Select a value -YesNo If YES, please specify the special consideration need Contact Contact Title Company Address Room City State Zip Code Country Phone Fax E-mail Provide complete annual maintenance billing contact information Company Name Contact Name Street Address City State ZIP Code Phone Email 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 HNI(s) within the time period specified by the assignment guidelines (Section 5.10) Certifies that the service to be provided with the HNI is for a public network that need to roam onto/from commercial public networks or for a service profile management system based in the U.S. for end user devices in the U.S. that can access such public network in the U.S. 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 Guidelines and IMSI Oversight Council Operating Procedures Understands and agrees that the use of any assigned HNI(s) in a manner other than in conformance with the assignment guidelines may result in reclamation of the HNI(s) A non-refundable ($325 US) application fee is required for each application processed. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question 10 + 2 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. Submit Form