Application For Certificate Of Authority And Affidavit Page 3
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1
2
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 3
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
6. The names of the principal executive officers or general partners of the applicant are:
(if more than four, please attach an 8 1/2" x 11" plain sheet of paper and continue listing each name and title)
Name
Title
Name
Title
Name
Title
Name
Title
7. Certifications and Signature of the Applicant:
The applicant hereby agrees to comply with all the applicable federal and state laws and
regulations; all generally applicable, nondiscriminatory local laws regarding the use and
occupation of any public right-of-way or highway in the construction, operation, maintenance
and repair of a video service network, including, without limitation, any local laws, enacted
pursuant to the police powers of the local government in which the video service network is
located; and has filed or will timely file with the Federal Communications Commission all the
forms required by that agency before offering video service.
X
Signature of Applicant
Name
State of
County of
20
, by
Subscribed and sworn on
Notary Signature
Nevada Secretary of State ACOA Page 3
Reset
Revised: 4-30-09
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