Gpsc Form 900-1 - Application For Certificate Of Authority To Provide Competitive Local Exchange Service

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Georgia Public Service Commission
244 W
S
, SW
ASHINGTON
TREET
A
G
30334-5701
TLANTA
EORGIA
APPLICATION FOR CERTIFICATE OF AUTHORITY
TO PROVIDE COMPETITIVE LOCAL EXCHANGE SERVICE
I. APPLICANT ADDRESS
NAME OF COMPANY
_______________________________________________________________________________________
ADDRESS: STREET
_______________________________________________________________________________________
______________________________________________________________________________________
CITY
____________________________
STATE _________________ ZIP CODE ______________________
TEL. NO. (
) _______________________________
FAX NO. (
) ____________________________________
NAME, ADDRESS AND TELEPHONE NUMBER OF EMPLOYEE DESIGNATED TO RECEIVE AND RESPOND TO COMMISSION
REQUESTS AND WHO WILL NOTIFY THE COMMISSION OF ANY CHANGES TO THE INFORMATION PROVIDED IN THIS
APPLICATION AND ADDRESS CORRECTIONS IN GEORGIA:
NAME ___________________________________________ TEL. NO. (
) ___________________________________________
TITLE ___________________________________________ FAX NO. (
) ___________________________________________
ADDRESS: (IF DIFFERENT FROM ABOVE)
STREET
_______________________________________________________________________________________
CITY
____________________________
STATE ________________
ZIP CODE ______________________
NOTE: FAILURE TO NOTIFY THE COMMISSION, IN WRITING, AS SOON AS POSSIBLE WHEN THERE IS A CHANGE IN THE
ADDRESS(ES) LISTED IN THE APPLICATION WILL SUBJECT THE APPLICATION AND SUBSEQUENT CERTIFICATE TO
CANCELLATION.
II. ATTORNEY OR AGENT ADDRESS
IF APPLICANT IS A NON-RESIDENT OF GEORGIA, GIVE NAME AND ADDRESS OF AN AGENT OR ATTORNEY IN FACT IN
THIS STATE UPON WHOM PROCESS MAY BE SERVED IN ANY SUIT AGAINST APPLICANT.
NAME OF FIRM ______________________________________________________________________________________________
ADDRESS: STREET ___________________________________________________________________________________________
__________________________________________________________________________________________
CITY
____________________________
STATE _________________
ZIP CODE __________________________
NAME _____________________________________________________________________________________________________
TEL. NO. (
) _____________________________________________
FAX NO. (
) ________________________________
GPSC FORM 900-1
Electronic Version
1

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