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Form A
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Entity requesting assignment
?
Select the type of entity requesting the HNI (select one)
- Select -
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 networks
Provider 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)
GPRS
EDGE
W-CDMA
HSPA
1xRTT
HRPD/EVDO
LTE/LTE Advanced
5G
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 -
Yes
No
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 -
Yes
No
special_considerations
Do special considerations apply, per section 8.4.2 or an addendum?
- Select -
Yes
No
Do special considerations apply, per section 8.4.2 or an addendum?
Contact
Contact Title
Company
Address
Room
City
State
Zip Code
Country
Phone
Fax
Email
Billing Contact
Provide complete annual maintenance billing contact information
Company Name
Contact Name
Street Address
City
State
Zipcode
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.
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