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Telecommunications Companies Annual Report - Washington Utilities And Transportation Commission - 2009

TELECOMMUNICATIONS COMPANIES

ANNUAL REPORT

Due May 1, 2010

Full name and address of Company

Correct name and address, if different than shown

WASHINGTON UTILITIES AND TRANSPORTATION COMMISSION

for the YEAR ENDED DECEMBER 31, 2009.

SECTION I

INQUIRIES CONCERNING THIS ANNUAL REPORT SHOULD BE ADDRESSED TO:

NAME:

TITLE:

ADDRESS:

CITY:

STATE:

ZIP:

TELEPHONE:

FAX:

E-MAIL:

The company must notify the Commission, in writing, of any changes to the above information.

SECTION II

TYPE OF PAYMENT - DO NOT SEND CASH IN THE MAIL

For Commission Use Only

Credit Card Authorization #:________________

___ Check ___ Money Order ___ AMEX ___ Visa ___ MasterCard ___ Discover

Expiration Date

Credit Card Number:

Month/Year

CERTIFICATION: I, the undersigned, under penalty for false statement, certify that the information is true, valid and correct, that I am authorized to

execute on behalf of the applicant, and that I agree to pay the above total amount according to card issuer agreement.

Name (Printed) _______________________________________________

Title ____________________________________

Signature_____________________________________________________

Date ____________________________________

For Commission Use Only

Reception Number:_________________

Reference:_________________

Payment ID:________________

Receivable #__________________

001-111-02-68-170-01:______________________ 001-111-02-68-170-11:___________________

001-111-02-68-032-20:____________________

Original to be mailed to the Washington Utilities and Transportation Commission, PO Box 47250, Olympia, WA 98504-7250

Web Site:

Telecommunications Companies Annual Report - Washington Utilities And Transportation Commission - 2009

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