ࡱ> ^`[\]'` bjbjVwVw 4"44X)TTTTTTTD 8X<D8RP4@l?AAAZK$ hrTdddTT4 djTT?d?TTw Ȼ- ΐ˶""0R&&Dw&Tw4ddddddRdddd8882Pd/888PhT@TTTTTT Florida Public Service Commission OFFICE OF TELECOMMUNICATIONS Application Form for Authority to Provide Telecommunications Company Service Within the State of Florida Instructions This form is used as an application for an original certificate and for approval of transfer of an existing certificate. In the case of a transfer, the information provided shall be for the transferee (See Page 8). Print or type all responses to each item requested in the application. If an item is not applicable, please explain. Use a separate sheet for each answer which will not fit the allotted space. Once completed, submit the original and one copy of this form along with a non-refundable application fee of $500.00 to: Florida Public Service Commission Office of Commission Clerk 2540 Shumard Oak Blvd. Tallahassee, Florida 323990850 (850) 4136770 A filing fee of $500.00 is required for the transfer of an existing certificate to another company. If you have questions about completing the form, contact: Florida Public Service Commission Office of Telecommunications 2540 Shumard Oak Blvd. Tallahassee, Florida 323990850 (850) 4136600 This is an application for (check one):  FORMCHECKBOX  Original certificate (new company).  FORMCHECKBOX  Approval of transfer of existing certificate: Example, a non-certificated company purchases an existing company and desires to retain the original certificate of authority rather that apply for a new certificate. Name of company:  FORMTEXT       Name under which applicant will do business (fictitious name, etc.):  FORMTEXT       Official mailing address: Street/Post Office Box:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT       Florida address: Street/Post Office Box:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT       Structure of organization:  FORMCHECKBOX  Individual  FORMCHECKBOX  Corporation  FORMCHECKBOX  Foreign Corporation  FORMCHECKBOX  Foreign Partnership  FORMCHECKBOX  General Partnership  FORMCHECKBOX  Limited Partnership  FORMCHECKBOX  Other, please specify:  FORMTEXT       If individual, provide: Name:  FORMTEXT      Title:  FORMTEXT      Street/Post Office Box:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone No.: FORMTEXT      Fax No.:  FORMTEXT      E-Mail Address:  FORMTEXT      Website Address:  FORMTEXT       If incorporated in Florida, provide proof of authority to operate in Florida. The Florida Secretary of State corporate registration number is:  FORMTEXT       If foreign corporation, provide proof of authority to operate in Florida. The Florida Secretary of State corporate registration number is:  FORMTEXT       If using fictitious name (d/b/a), provide proof of compliance with fictitious name statute (Chapter 865.09, FS) to operate in Florida. The Florida Secretary of State fictitious name registration number is:  FORMTEXT       If a limited liability partnership, please proof of registration to operate in Florida. The Florida Secretary of State registration number is:  FORMTEXT       If a partnership, provide name, title and address of all partners and a copy of the partnership agreement. Name:  FORMTEXT      Title:  FORMTEXT      Street/Post Office Box:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone No.: FORMTEXT      Fax No.:  FORMTEXT      E-Mail Address:  FORMTEXT      Website Address:  FORMTEXT       If a foreign limited partnership, provide proof of compliance with the foreign limited partnership statute (Chapter 620.169, FS), if applicable. The Florida registration number is:  FORMTEXT       Provide F.E.I. Number:  FORMTEXT       Who will serve as liaison to the Commission in regard to the following? (a) The application: Name:  FORMTEXT      Title:  FORMTEXT      Street Name & Number:  FORMTEXT      Post Office Box: FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone No.: FORMTEXT      Fax No.:  FORMTEXT      E-Mail Address:  FORMTEXT      Website Address:  FORMTEXT       (b) Official point of contact for the ongoing operations of the company: Name:  FORMTEXT      Title:  FORMTEXT      Street Name & Number:  FORMTEXT      Post Office Box: FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone No.: FORMTEXT      Fax No.:  FORMTEXT      E-Mail Address:  FORMTEXT      Website Address:  FORMTEXT       (c) Where will you officially designate as your place of publicly publishing your schedule (a/k/a tariffs or price lists)?  FORMCHECKBOX  Florida Public Service Commission  FORMCHECKBOX  Website  Website address: FORMTEXT        FORMCHECKBOX  Other  Please provide address:  FORMTEXT       List the states in which the applicant: (a) has operated as a telecommunications company.  FORMTEXT       (b) has applications pending to be certificated as a telecommunications company.  FORMTEXT       (c) is certificated to operate as a telecommunications company.  FORMTEXT       (d) has been denied authority to operate as a telecommunications company and the circumstances involved.  FORMTEXT       (e) has had regulatory penalties imposed for violations of telecommunications statutes and the circumstances involved.  FORMTEXT       (f) has been involved in civil court proceedings with another telecommunications entity, and the circumstances involved.  FORMTEXT       Have any of the officers, directors, or any of the ten largest stockholders previously been: (a) adjudged bankrupt, mentally incompetent (and not had his or her competency restored), or found guilty of any felony or of any crime, or whether such actions may result from pending proceedings.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provide explanation.  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FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provide explanation and list the certificate holder and certificate number.  FORMTEXT       (c) an officer, director, partner or stockholder in any other Florida certificated or registered telephone company.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, give name of company and relationship. If no longer associated with company, give reason why not.  FORMTEXT       Submit the following: (a) Managerial capability: resumes of employees/officers of the company that would indicate sufficient managerial experiences of each. Please explain if a resume represents an individual that is not employed with the company and provide proof that the individual authorizes the use of the resume. (b) Technical capability: resumes of employees/officers of the company that would indicate sufficient technical experiences or indicate what company has been contracted to conduct technical maintenance. Please explain if a resume represents an individual that is not employed with the company and provide proof that the individual authorizes the use of the resume. (c) Financial Capability: applicant s audited financial statements for the most recent three (3) years. If the applicant does not have audited financial statements, it shall so be stated. Unaudited financial statements should be signed by the applicant s chief executive officer and chief financial officer affirming that the financial statements are true and correct and should include: the balance sheet, income statement, and statement of retained earnings. Note: It is the applicant s burden to demonstrate that it possesses adequate managerial capability, technical capability, and financial capability. Additional supporting information can be supplied at the discretion of the applicant. This Page Must Be Completed And Signed Regulatory Assessment Fee: I understand that all telephone companies must pay a regulatory assessment fee. Regardless of the gross operating revenue of a company, a minimum annual assessment fee, as defined by the Commission, is required. Receipt and Understanding of Rules: I acknowledge receipt and understanding of the Florida Public Service Commission's rules and orders relating to the provisioning of telecommunications company service in Florida. Applicant Acknowledgement: By my signature below, I, the undersigned officer, attest to the accuracy of the information contained in this application and attached documents and that the applicant has the technical expertise, managerial ability, and financial capability to provide telecommunications company service in the State of Florida. I have read the foregoing and declare that, to the best of my knowledge and belief, the information is true and correct. I attest that I have the authority to sign on behalf of my company and agree to comply, now and in the future, with all applicable Commission rules and orders. Further, I am aware that, pursuant to Chapter 837.06, Florida Statutes, "Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 and s. 775.083." I understand that any false statements can result in being denied a certificate of authority in Florida. Company Owner or Officer Print Name: FORMTEXT      Title: FORMTEXT      Telephone No.:  FORMTEXT      E-Mail Address: FORMTEXT       Signature:Date: Certificate Transfer As current holder of Florida Public Service Commission Certificate Number  FORMTEXT     , I have reviewed this application and join in the petitioner's request for a transfer of the certificate. Company Owner or Officer Print Name:  FORMTEXT      Title:  FORMTEXT      Street/Post Office Box:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Telephone No.: FORMTEXT      Fax No.:  FORMTEXT      E-Mail Address:  FORMTEXT       Signature:Date:     PAGE  FORM PSC/TEL 162 (12/12) Page  PAGE 8 of  NUMPAGES 8 Application to Provide Telecommunications Company Service Within the State of Florida - Commission Rule No. 25-4.004, F.A.C. HJtPxz|||qdR#h=5:CJ OJQJ\^JaJ h=5OJQJ\^Jh=5OJQJ^Jh=5>*OJQJ^J)jh=6OJQJU^JmHnHu$jWh=6OJQJU^Jh=6OJQJ^Jjh=6OJQJU^Jh=>*OJQJ^J!jWh=OJQJU^Jjh=OJQJU^Jh=OJQJ^JlFHTV|$ 8@ a$ 8@ $ 8@ a$ $ @ a$$ & F 8@ a$$ 8@ a$$ 8@ ^a$JL@B"$ 246JLNоооЛ|qЛaNa$jXh=OJQJU\^Jjh=OJQJU\^Jh=:OJQJ^J h=:>*CJOJQJ^JaJh=56OJQJ\^Jh=OJQJ\^Jh=5OJQJ^Jh=5OJQJ\^J#h=5:CJOJQJ\^JaJh=OJQJ^J#h=5:CJ OJQJ\^JaJ &h=5:>*CJ OJQJ\^JaJ 4\^mYkd~X$$IfTlD0, t644 laT 8@ $Ifl 8@ $ 8@ a$ NXZ^jln$&2FJT^`"ŲŧŔŁЧoah=CJOJQJ^JaJ#h=5:>*CJ OJQJ^JaJ $jt[h=OJQJU\^J$jPZh=OJQJU\^Jh=>*OJQJ^J$j,Yh=OJQJU\^Jh=OJQJ\^Jh=OJQJ^Jjh=OJQJU\^J)jh=OJQJU\^JmHnHu&^lp 8@ $IflYkdY$$IfTlD0, t644 laT 8@ $Ifl(*0Ykd[$$IfTlD0, t644 laT 8@ $IflYkdZ$$IfTlD0, t644 laT*,.02HJVXZ\]ykd\$$Ifl\<$ t$644 la 8@ $Ifl 8@  \` RTn$ 8@ $Ifa$l$ 8@ $Ifa$l$ 8@ a$ 8@  $ a$$ 8@ a$ "$8:F PRTlnpȷ傒oZM:$j _h=OJQJU\^Jh=>*OJQJ\^J)jh=OJQJU\^JmHnHu$j]h=OJQJU\^Jjh=OJQJU\^Jh=OJQJ\^Jh=>*CJOJQJ^JaJh=:OJQJ^J h=:>*CJOJQJ^JaJh=OJQJ^J$jr]h=>*OJQJU^Jh=>*OJQJ^Jjh=>*OJQJU^Jo$ 8@ $Ifa$l$ 8@ $Ifa$lUkd^^$$Ifl,0d $+ 9 t644 la(*.<>RTV`bdfvx аНЊw$jdh=OJQJU\^J$jHch=OJQJU\^J$jbh=OJQJU\^J$j2`h=OJQJU\^Jh=>*OJQJ\^Jh=OJQJ\^J)jh=OJQJU\^JmHnHujh=OJQJU\^J,,o$ 8@ $Ifa$l$ 8@ $Ifa$lUkd_$$Ifl,0d $+ 9 t644 la,.<do$ 8@ $Ifa$l$ 8@ $Ifa$lUkdVa$$Ifl,0d $+ 9 t644 ladfvo$ 8@ $Ifa$l$ 8@ $Ifa$lUkdb$$Ifl,0d $+ 9 t644 lao$ 8@ $Ifa$l$ 8@ $Ifa$lUkdc$$Ifl,0d $+ 9 t644 lao$ 8@ $Ifa$l$ 8@ $Ifa$lUkd)e$$Ifl,0d $+ 9 t644 la 24HJLVXZ\~ݽݽݽݽݽ|tptptptpfjh80JUh8jh8Uh=h=OJQJ^J$j"hh=OJQJU\^J$jfh=OJQJU\^Jh=>*OJQJ\^Jh=OJQJ\^J)jh=OJQJU\^JmHnHujh=OJQJU\^J$jeh=OJQJU\^J&2Zo$ 8@ $Ifa$l$ 8@ $Ifa$lUkdNf$$Ifl,0d $+ 9 t644 laZ\~o$ 8@ $Ifa$l$ 8@ $Ifa$lUkdsg$$Ifl,0d $+ 9 t644 layyyy 8@ $Ifl 8@ k^`kUkdh$$Ifl,0d $+ 9 t644 la pnnnnnnnnll 8@ k^`kykdGi$$Ifl\<$ t$644 la  8@ k^`k$x^xa$ hx]h^x Zx]Z^xh]h&`#$$a$ <Fbdprtv~h=$h5.{5CJOJQJaJmHnHu"jh85CJOJQJUaJh5.{5CJOJQJaJh85CJOJQJaJh8jh80JU h80J2 00&P/ =!"#$%` DCheck1ACheck this box if this is an original certificate or new company.DCheck2Example, a non-certificated company purchases an existing company and desires to retain the original certificate of authority rather than apply for a new certificate.cCheck this box if for approval of transfer of existing certificate. Press F1 for more information.D2Text33Enter the name of the company.D2Text6:Enter the name under which the applicant will do business.$D2Text17WEnter street or post office box number of the official mailing address for the company.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aD2Text19Enter the city.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aDText20Enter the state.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aDText21Enter the zip code.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ a$D2Text17WEnter street or post office box number of the official mailing address for the company.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aD2Text19Enter the city.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aDText20Enter the state.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aDText21Enter the zip code.$$If!vh5+ 59#v+ #v9:Vl t06,5+ 59/ aDeCheck5=Check this box if the company will be owned by an individual.DeCheck94Check this box if the company will be a corporation.DeCheck6<Check this box if the company will be a foreign corporation.DeCheck10<Check this box if the company will be a foreign partnership.DeCheck7<Check this box if the company will be a general partnership.DeCheck11<Check this box if the company will be a limited partnership. DeCheck8LCheck this box if the company will be something other than what is listed. 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xxdC)C) 3Q X!?=2C:\Documents and Settings\cbeard\Local Settings\Temporary Internet Files\008-RAD-Application Telecommunications Company-DRAFT.dot'** FLORIDA PUBLIC SERVICE COMMISSION **Catherine BeardJulie PhillipsD         Oh+'0 P ht    (** FLORIDA PUBLIC SERVICE COMMISSION **Catherine Beard<008-RAD-Application Telecommunications Company-DRAFT.dotJulie Phillips13Microsoft Office Word@Vn @^Y6@&@-+-#՜.+,00 hp  $Florida Public Service CommissionKC)' (** FLORIDA PUBLIC SERVICE COMMISSION ** Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJLMNOPQRTUVWXYZ_Root Entry F9-aData !j1TablejWordDocument4"SummaryInformation(KDocumentSummaryInformation8SCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q