Gpsc Form 900-1 - Application For Certificate Of Authority To Provide Competitive Local Exchange Service Page 2
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14III. ORGANIZATION
1.
TYPE OF ORGANIZATION:
(CHECK ONE)
[ ]
LLC
[ ]
INDIVIDUAL
[ ]
PARTNERSHIP
[ ]
CORPORATION
[ ]
MUTUAL OR COOPERATIVE (INC./UNINC.)
[ ]
OTHER (SPECIFY: _________________________________________________________________________________)
2.
SECRETARY OF STATE:
IF TYPE OF ORGANIZATION IS A CORPORATION OR LIMITED PARTNERSHIP,
INSERT SECRETARY OF STATE’S CHARTER OR FILE IDENTIFICATION
NUMBER (7 DIGITS)
_________________________
3.
IF A CORPORATION, ATTACH COPY OF CHARTER MARKED “EXHIBIT A”. ALSO ATTACH A LIST OF ALL
DIRECTORS AND PRINCIPAL STOCKHOLDERS WITH THE NUMBER OF SHARES HELD BY EACH MARKED
“EXHIBIT
B”, AND GIVE NAME AND ADDRESSES OF THE FOLLOWING OFFICERS:
PRESIDENT ____________________________________ ADDRESS ______________________________________________
_____________________________________________
V. PRESIDENT __________________________________
ADDRESS ______________________________________________
_____________________________________________
TREASURER ____________________________________
ADDRESS ______________________________________________
_____________________________________________
SECRETARY ____________________________________
ADDRESS ______________________________________________
_____________________________________________
STATE AND DATE OF INCORPORATION:
STATE ___________________________ DATE _______________________
4.
IF APPLICANT IS A PARTNERSHIP OR COOPERATIVE, GIVE NAMES AND ADDRESSES OF PARTNERS, OFFICERS
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5.
ARE DIRECTORS, PARTNERS, OFFICERS, OR MEMBERS AFFILIATED WITH ANY OTHER TELECOMMUNICATIONS
________________________________________________________________________________________________________
________________________________________________________________________________________________________
IF SO, WHAT COMPANY AND HOW AFFILIATED? ________________________________________________________
________________________________________________________________________________________________________
IV. EXISTING AUTHORITY
1.
A)
DOES THE APPLICANT OR ANY AFFILIATE PRESENTLY HAVE EXISTING CERTIFICATE AUTHORITY IN
GEORGIA?
GPSC FORM 900-1
Electronic Version
2
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