Application For Certificate Of Authority And Affidavit Page 2
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3ROSS 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 2
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
4. Application Fee:* Based upon the information that has been set forth in section 2 of this
form, the application fee of this Certificate of Authority and Affidavit is:
$250.00 - Service area located entirely within the territorial boundaries of a county whose
population is less than 50,000.
$500.00 - Service area located in whole or in part within the territorial boundaries of a county
whose population is 50,000 or more but less than 100,000.
$1,000.00 - Service area located in whole or in part within a county whose population is
100,000 or more.
5. Certificate Fee:* Based upon the information that has been set forth in section 2 of this
form or by election of the statewide certificate, the certificate fee of this Certificate of Authority
and Affidavit is:
(a) $250.00 - Service area located entirely within the territorial boundaries of a town,
township or city whose population is less than 1,000, regardless of the population of the
county.
(b) $2,500.00 - Service area located entirely within the territorial boundaries of a town,
township or city whose population is 1,000 or more but less than 50,000, regardless of the
population of the county.
(c) $2,500.00 - Service area located entirely within the territorial boundaries of a county
whose population is less than 50,000, unless the provisions of 5(a) or 5(b) apply.
(d) $15,000.00 - Service area located in whole or in part within the territorial boundaries of
a county whose population is 50,000 or more but less than 100,000, unless the provisions of
5(a), 5(b) or 5(e) apply.
(e) $25,000.00 - for a Service area located in whole or in part within the territorial
boundaries of a county whose population is 100,000 or more unless the provisions of 5(a) or
5(b) apply.
or
$25,000.00 - Certificate of Authority that permits, but does not require, applicant to
provide video service within one or more service areas located anywhere in this state as
designated in this application and affidavit.
*Required Filing Fee = Application Fee + Certificate Fee
Nevada Secretary of State ACOA Page 2
Revised: 4-30-09
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