AAC 5/20 Applicant Submission of Authorized Contractor

Valid in AL, FL, GA, IN, KS, MO, MS, NC, NV, OK, SC, TN, TX, WI

Applicant Information

Applicant (Company Name) Click or tap here to enter text. Applicant tracking # Optional

Authorizer Name Click or tap here to enter text. Authorizer Title Click or tap here to enter text.

Email Click or tap here to enter text. License/SA Agreement or LSB# Click or tap here to enter text.

Application Type

Initial or Change request Choose an item.

If a Change Request, please tell us what is changing Click or tap here to enter text.

Contractor Work Authorization Type Choose an item.

Contract Company Information

Contract Company Name Click or tap here to enter text.

Contract Contact Name Click or tap here to enter text.

Contract Company Address Click or tap here to enter text. City Click or tap here to enter text.

State Click or tap here to enter text. Zip Click or tap here to enter text. Telephone Number Click or tap here to enter text.

Contract Company Email Click or tap here to enter text.

Effective Date Click or tap to enter a date.

Do you want an expiration date? Choose an item.

If you entered yes to the question above, please select an expiration date Click or tap to enter a date.

State(s) Authorized to Perform Work: ☐AL, ☐FL, ☐GA, ☐IN, ☐KS, ☐MO, ☐MS, ☐NC, ☐NV, ☐OK, ☐SC, ☐TN, ☐TX, ☐WI

Contract Company Insurance Information

Contract Company Insurance Name Click or tap here to enter text.

Contract Company Insurance Address Click or tap here to enter text. City Click or tap here to enter text.

State Click or tap here to enter text. Zip Click or tap here to enter text. Telephone Number Click or tap here to enter text.

Certification and Signature

As a responsible representative of my company, with a Letter of Authorization (LOA), I certify that the contractor I identified above meets or exceeds the minimum requirements established by the FCC in 47 C.F.R. §1.1422(c) and listed below:

Contractor agrees to follow AT&T's published safety and operational guidelines, as identified in Attaching Party's structure access agreement covering its attachments to AT&T's poles

Contractor acknowledges that it can read and follow licensed-engineered pole designs for make-ready work

Contractor agrees to follow all local, state, and federal laws and regulations including, but not limited to, the rules regarding Qualified and Competent Persons under the requirements of the Occupational Safety and Health Administration (OSHA) rules

Contractor agrees to meet or exceed safety and reliability thresholds set by AT&T, which are available for review upon request

Contractor is adequately insured or has established an adequate performance bond for the make-ready work it will perform, including work it will perform on facilities owned by existing attachers, including AT&T

Any submissions of this form will not be accepted if submitter has not executed an agreement with AT&T reflecting the changes resulting from the FCC 18-111 Order.

Authorized Signature Electronic signature permitted Printed Name Click or tap here to enter text.

Date Click or tap to enter a date.

AT&T Official Use Only Email to g14158@att.com

AT&T Representative Name Click or tap here to enter text. ATTUUID Click or tap here to enter text.

Approved Choose an item. Denied reason Click or tap here to enter text.

Date Form Received Click or tap to enter a date. Date Form Response Click or tap to enter a date.