Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 Page 3

AFFIDAVIT

The provider hereby affirms that he/she has received and read a copy of the Georgia Public Service

Commission’s Rules and Regulations for Payphone Service Providers for Registration (GPSC Utility Rule 515-

12-1-.31), understands the requirements and penalties set forth therein, and will provide this service in full

compliance with said Rules and Regulations.

Finally, this document must be notarized and returned to the Commission Staff prior to registration.

______________________________________

(Company)

______________________________________

(Signature)

______________________________________

(Signer’s Typed Name and Title)

______________________________________

(Date)

Subscribed and sworn before me this

_______ day of ________________, 20_____.

_____________________________________

(Notary Public)

GPSC FORM 200-1, Revised: 09/11/07

Electronic Version

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