MPSCS - Bi-Directional Amplifier Data Form

Bi-Directional Amplifier Data Form

*Completed by

*Date

*Email

User Agency Contact Information

* Agency/Company Name

* Contact Name

Address

City

Zip Code

* Phone Number

* Email

Maintenance Contact

Same as above

Maintenance Contact Agency/Company Name

Maintenance Contact Name

Maintenance Contact Address

Maintenance Contact City

Maintenance Contact Zip Code

Maintenance Contact Phone Number

Maintenance Contact Email

BDA System Information

* BDA make and Model

* BDA System Type

* BDA Service Location Type

* BDA Frequency Band

BDA Donor Site (if known)

BDA RF ERP to Donor Site (watts)

BDA Location Information

BDA Location Address

BDA Location City

BDA Location Zip Code

and/or BDA Location Coordinates

Latitude

Longitude

BDA Installation Location Description

BDA Coverage Area Description

Additional Information

* Spam Block: (What's this?) Add "one" plus "six" and type the numeric (integer) answer here: