Application For Certificate Of Authority And Affidavit

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ROSS MILLER
Secretary of State
204 North Carson Street, Suite 4
Carson City, Nevada 89701-4520
(775) 684 5708
Website:
Application for Certificate
of Authority and Affidavit
(PURSUANT TO NRS CHAPTER 711)
Page 1
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
1. Name of Applicant:
2. Following is a description of each service area designated by the applicant in which the
applicant intends to provide video service:
Attached is an 8 1/2" x 11" map of each such service area that shows the territorial
boundaries of each local government located, in whole or in part, within the service
area.
(mark box to
confirm)
3. The location of the principal place of business of the applicant is:
Street Address
City
State
Zip Code
Nevada Secretary of State ACOA Page 1
Revised: 4-30-09

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