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Exhibit A - Form of Pole License Page 1 EXHIBIT A FORM OF POLE /FACILITIES License The following license is for use of the City’s __[X]___POLE and/or ___[X]___ASSOCIATED FACILITIES as indicated by the individual license terms set forth below, pursuant to the Master License Master License between [Wireless Company] and City of San Leandro [For City Staff only: Check and complete individual licenses for Pole and/or Associated Facilities, as applicable.] __[X]___ Pole License No. [Start with Year-1 and number each subsequent application consecutively (e.g. 2018-1).] In accordance with Section 6.5 of the Master License, Licensee submits to the City two partially executed counterparts of this form of Pole License and each of the following as its Pole License application: 1.Exhibit A-1, designating all Pole Locations that Licensee seeks to be included in the License Area under this Pole License and noting (if known) whether any requested City Pole is a Nonstandard City Pole; 2.Exhibit A-2, complete and final plans and specifications for Equipment to be installed in the License Area subject to Regulatory Approvals; 3.The sum of $for the initial Administrative Payment in amounts based on the number of City Poles identified in Exhibit A-1, subject to Section 6.7 of the Master License; and 4.If not previously provided, the Emissions Report. Licensee acknowledges that: (a) this Pole License will not be effective until the City returns a fully executed copy to Licensee; (b) the City may require Licensee to supplement the Administrative Payment on conditions specified in Section 6.6 of the Master License; (c) Licensee will not have the right to access or install Equipment on the License Area until after Licensee has: (i) submitted a complete Acknowledgment Letter to the City with all information and funds required; (ii) submitted insurance information to City as specified in Article 19; and (iii) the City has provided notice to proceed by returning to Licensee a countersigned copy of the Acknowledgment Letter. This Pole License is executed and effective as of the last date written below and, upon execution will be the City’s authorization for the City’s Engineering and Transportation Department to begin its review of the Pole Locations and plans and specifications proposed in this Pole License application. __[X]___ Associated Facilities License No. [Start with Year-1 and number each subsequent application consecutively (e.g. 2018-1).] This Associated Facilities License (“License”), is made this _____ day of ____________, 20____, between the City of San Leandro, a California charter (“City”), and ____________________ (“Licensee”), with its principal offices at ______________________