CCN New Customer Application

Today's date*

Agency type*
First ResponderSchool DistrictPublic UtilityGeneral GovernmentOther

Agency Name*

Physical street address*

City*

State*

Zip Code*

Point of Contact (POC)*

POC e-mail address*

POC Phone Number*

Operational Service Area*

Operational required hours of service*

24/7/365 other

If other selected, provide number of days per year*

If other selected, provide number of hours per day*

Need to communicate with your local Dispatch?*

Yes No

Number of portable radio subscribers*

Number of mobile radio subscribers*

Do you have any security requirement for voice communications?*

AES Encryption DES Encryption N/A

List agencies you communicate with

Additional information you would like to share

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