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Form A - Application
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Entity requesting assignment
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General description of the service to be provided, including area of service, and whether GSM-based or ANSI-41 CDMA-based service that requires the issuance of an MNC in the format XX0. If an MNC not in the XX0 format (i.e. a 3-digit MNC) can be used it must be specifically requested in this section.
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Wireless license number
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Date of issuance (mm/dd/yyyy)
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Fax copy of Wireless License to IMSI Administrator at (732)336 6999
Is this request associated with a request for multiple mobile network codes (MNCs), per Section 8.4.3?
Yes
No
If YES, please list other wireless licenses associated with this request
Do special considerations apply, per section 8.4.2 of IMSI Assignment Guildlines or an addendum?
Yes
No
If YES, please specify the special consideration needed
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Contact Name
Contact Title
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Company
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Street
Room
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City
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State / Province
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Zip Code / Postal Code
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Country
USA
Anguilla
Antigua
Argentina
Australia
Bahamas
Barbuda
Barbados
Bermuda
Bolivia
Brazil
British Virgin Islands
British West Indies
Canada
Caicos
Cayman Islands
Chile
China
Colombia
Costa Rica
Curacao
Dominica
Dominican Republic
Ecuador
El Salvador
France
Grenada
Grenadines
Guam
Guatemala
Honduras
Hong Kong
Israel
Jamaics
Japan
Korea
Marianas
Mexico
Montserrat
Netherlands Antilles
Nevis
New Zealand
Nicaragua
Panama
Paraguay
Peru
Phillipines
Puerto Rico
St. Kitts
St. Lucia
St. Maarten
Tobago
Trinidad
Turks
Uruguay
US Virgin Islands
Venezuela
Other
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Phone
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Fax
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Email
There is a non-refundable ($250 US) application fee for each application processed.
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