Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 (Page 4 of 5) in pdf

Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 Page 4

AGREEMENT

OFFICER OR ATTORNEY:

NAME __________________________________________

TITLE __________________________________________

ADDRESS:

Street ______________________________________

City _________________ State ______ Zip Code ____________

Tel. No. (

) ____________________

The provider agrees to abide by all applicable laws under the Official Code of Georgia Annotated (O.C.G.A.),

all applicable rules and regulations and any further amendments or supplements thereto of the Commission.

Further, provider agrees to abide by all applicable Interexchange and Local Exchange Companies’ tariffs.

The provider understands that the registration sought herein applies only to the provision of Payphone Service

Providers. If another service is desired, the applicant must file and have approved the appropriate application(s)

and tariff(s) from the Georgia Public Service Commission before offering and providing desired services.

__________________________________________

(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

Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 Page 4