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Exhibit A - Form of Pole License <br />Page 1 <br />EXHIBIT A <br />FORM OF POLE LICENSE <br />Master License between [Wireless Company] and City of San Leandro Pole License <br />No. [Start with Year-1 and number each subsequent application consecutively (e.g. 2018-1).] <br />In accordance with Section 6.5 of the Master License, Licensee submits to the City two partially <br />executed counterparts of this form of Pole License and each of the following as its Pole License <br />application: <br />1.Exhibit A-1, designating all Pole Locations that Licensee seeks to be included in the <br />License Area under this Pole License and noting (if known) whether any requested City <br />Pole is a Nonstandard City Pole; <br />2.Exhibit A-2, complete and final plans and specifications for Equipment to be installed in <br />the License Area subject to Regulatory Approvals; <br />3.The sum of $for the initial Administrative Payment in amounts <br />based on the number of City Poles identified in Exhibit A-1, subject to Section 6.7 of the <br />Master License; and <br />4.If not previously provided, the Emissions Report. <br />Licensee acknowledges that: (a) this Pole License will not be effective until the City returns a fully <br />executed copy to Licensee; (b) the City may require Licensee to supplement the Administrative <br />Payment on conditions specified in Section 6.6 of the Master License; (c) Licensee will not have <br />the right to access or install Equipment on the License Area until after Licensee has: (i) submitted <br />a complete Acknowledgment Letter to the City with all information and funds required; (ii) <br />submitted insurance information to City as specified in Article 19; and (iii) the City has provided <br />notice to proceed by returning to Licensee a countersigned copy of the Acknowledgment Letter. <br />This Pole License is executed and effective as of the last date written below and, upon execution <br />will be the City’s authorization for the City’s Engineering and Transportation Department to begin <br />its review of the Pole Locations and plans and specifications proposed in this Pole License <br />application. <br />LICENSEE: <br />[Wireless Company], a ________[California corporation, Nevada LLC, etc.] <br />By: <br />Its: <br />Date: