LRS - Application Form PRESIDENT OF THE OFFICE OF ELECTRONIC COMMUNICATIONS

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1 Date LRS (company's stamp) ref. sign:... PRESIDENT OF THE OFFICE OF ELECTRONIC COMMUNICATIONS Issue No.: The application concerns the station: APPLICATION for a license on usage of radio devices for earth satellite station and frequency utilisation or introducing of changes into permission SNG VSAT HUB Broadcasting OTHER New Change Renew of the license Number and date of previous license (if it was issued): Number of license for HUB station (concerns the terminals' network) On the basis of what document legitimise for activity in the telecommunications field the applicant apply for a license? KRRiT concession telecommunication permission declaration of economic activity: Was a copy of above document delivered? YES NO Date of isses of entitlement:. Validation date of entitlement: Applicant's / Proxy's signature * The application should be completed clearly according to instruction * For VSAT terminals istead of points: 11c, 11d, 12, 13a, 13b, 14, 15, 16 complete of appropriate number of pages - Part X of the form Page 1 of 10

2 Part A 1. Full name of the entity, to which the permission will be issued. Application Data Applicant address postal code, town/city street, number province telephne, fax, 2. Billing address (if different from above) postal code, town/city street, number province telephone, fax, 3. Who is designated to keep contact On technical matters: in order to deliver additional information or clarification? Name Telephone No. In administration matters: Name Telephone No. 4. The organizational and legal-entity form of applicant applying for license 5. Type of station Disposal of frequency in fixed-satellite service used to sending of broadcasting signals in the Earth-satellite relationship, made by one fixed-satellite earth station, * VSAT networks * Station used by budget unit exlusively for training purposes Page 2 of 10

3 6. Satellite name and satellite operator name 7. Is satellite traveling on geostationary orbit? Yes No If yes enter the nominal orbital location deg. of orbital long. with an accuracy of 0,1 8. Satellite beam indication Transmission Reception 9. Does the lease agreement was entered for staellite transponder with proper organisation Yes No of satellite communication? If yes, attach the copy of agreement 10.a) When the earth-station starts operation? day month year Proposed date of expiration of radio permission day month year [According to art. 148 ust. 3. Act of 16 July 2004 Telecommunications Law (Dz. U. Nr 171 poz. 1800) radio licences for radiocommunication services other than amateur radiocommunication service shall be issued for a maximum of 10 years.] 10.b) Fixed working hours Page 3 of 10

4 Part B 11.a) Type of earth station LRS - Application Installation Form data Fixed Mobile Manufacturer of earth station Producent Model Serial numer 11.b) Confirmation document of conformity equipment with essiencial requirements Document type, Certyfication Body, Issue date (attach the copy of document) 11.c) Location of earth station (place of installation or area, if the gegraphical location can not be specified) 11.d) Proposal of the station name (max. 20 alphanumeric signs) Coordinates Deg. Longitude E W Latitude N Min Sec Deg. S Min Sec 12. Is the horizon profile attached Yes No around earth station? If not, please indicate when will be delivered Please attach a chart or table showing the elevation angle of horizon with steps every 5 deg. In east direction from north latitude around the earth station it is in the range of 0 to 360 deg. Horizon elevation angle is the angle seen from the midpoint of the earth station's antenna contained between horizontal plane and the radius erected from this point to the natural physical horizon. During calculating this angle unstable object should not be considered. Page 4 of 10

5 13.a) What minimum angle of elevation LRS - Application Form in the direction of the maximum radiation of the antenna (with accuracy of 0,1 in relation to the horizontal plane) is planned? 13.b) What azimuth angles range in the direction of the maximum radiation of the antenna (with accuracy of 0,1 from north latitude line clockwise) is planned? from to 13.c) What is the distance from nearest airport fence if the terminal does not meet requirements of Regulation of the Infrastructure Ministry of 24 October 2005r.(Dz.U. z 2005, nr 230 poz.1955) Indicate for each terminal which do not fullfill above requirements meters 14. The altitude in location of the satellite station [above sea level ] meters 15. At what latitude,above sea level, the base of the antenna system is situated? meters 16. At what latitude the highest point of antenna system is situated? meters The antenna system includes aerial mast (including additional elements like lightning arrester) on which the antenna is mounted and any supporting structures. 17.a) Antenna type 17.b) Dimensions diameter or (. x. ) [m] meters Page 5 of 10

6 Part C Details data for transmitting part station station class type of service 18. Description of station 19. Assigned Frequency of Band Beam frequency, carrier wave width used band width and beam used 1 MHz/GHz khz 2 MHz/GHz khz 3 MHz/GHz khz 4 MHz/GHz khz 5 MHz/GHz khz Delete as appropriate 20. For each type of modulation Band indicate: width Emission Desc. Total PEP Power density required band width, emission and description, total a dbw dbw/hz peak envelope power (PEP) and power density b dbw dbw/hz (per 1Hz), conducted to the antenna input c dbw dbw/hz d dbw dbw/hz e dbw dbw/hz 21. Minimal band width Band which will be used witdth Emission Desc. Maximum PEP Minimum PEP 22. Indicate maximum and minimum value of peak 1 dbw dbw envelope power (PEP) for each carrier wave 2 dbw dbw 3 dbw dbw 4 dbw dbw 5 dbw dbw Page 6 of 10

7 Antenna pattern Transmission Reception 23. What is the antenna gain in the direction of maximum radiation( db/ relative to the isotropic antenna)? 24. What is the beam width ( in degrees) between points of half power? If beam asymetry occurs, attach antenna pattern 25. Indicate natenna pattern published in ITU-R publications, which should be used for coordination purpose or attach antenna pattern prepared on the basis of measurement ( taking as a reference direction of maximum radiation 26. What is the type of polarization and polarization plane emitted wave in direction of maximum radiation? Page 7 of 10

8 Modulation characteristic for each carrier wave LRS - Application Form FM For carrier frequency modulated by signal of multiple telephony with frequency division (FDM - FM) or by signal with similar feature 27. What are: the smallest and the largest smallest frequency of the basis band largest and effective deviations of test signal's frequency as a function of basis band frequency? deviation... TV For carier frequency modulated by total video signal of colour television modulating signal 28. What are the video signal standard standard (together with standard used for color) and frequency deviation and frequency preemphasis characteristic? deviation preemphasis characteristics Indicate (if applicable) data sound signals and others accompanying video signal... PM For carrier wave with digital phase modulation (PSK) transmission 29. Please indicate transsmision speed speed (bit/s ) and number of phases number of phases Page 8 of 10

9 AM For carrier wave modulated in amplitude (together with single-sideband modulation) modulating signal 30. Indicate modulating signal type and type of amplitude modulation amplitude modulation 31. For each type of modulation give also detailed information which can by useful for harmful interferences analysis (coordination) 32. For each type of modulation give (if applicable) characteristics of energy dispersion Page 9 of 10

10 Part D LRS - Application Form Detailed information about receiving earth station 33. Descryption of station calss of station sort of provided service Assigned Band Beam frequency width used 34. Assigned frequency, band width 1 MHz/GHz* khz and beam used 2 MHz/GHz khz 3 MHz/GHz khz 4 MHz/GHz khz 5 MHz/GHz khz 6 MHz/GHz khz *Delete as appropriate 35. Noise temperature Indicate of noise temperature of receiving system (in Kelvin) K 36. For each type of Band Noise temerature Transmission modulation indicate: width Emission Desc. of receiving system gain required band width, emission and description, noise temperature a K db of receiving system and transmission gain. b K db c K db d K db e K db f K db Page 10 of 10

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