Psp Change Of Name Or Address Application (Page 2 of 4) in pdf

Psp Change Of Name Or Address Application Page 2

Certification

I certify that I am the holder of certificate number _______ and that I desire that the name and/or

address appearing on this certificate be changed as indicated above. I understand that the new

name and address will appear on the certificate and that the posted information at my payphones

must reflect the new name and address. I understand that I am responsible for requesting that the

telephone company change its records to reflect any name changes on my certificate.

__________________________

_____________________________________________

Date

Signature of Applicant

_____________________________________________

Name typed

The person whose signature appears

above is (check appropriate block):

[ ] Sole proprietor

[ ] General partner

[ ] Management official of applicant

(specify title: _______________________ )

Verification

STATE OF _______________________

COUNTY OF _____________________

The above-named ____________________________________________________________,

personally appeared before me this day and, being first duly sworn, says that the facts stated in the

foregoing application and any exhibits, documents, and statements thereto attached are true as he

verily believes.

WITNESS my hand and notarial seal, this _________ day of _____________, 20____.

My Commission expires ____________________

______________________________________

Signature of Notary Public

______________________________________

Typed name of Notary Public

NOTE TO NOTARY: See verification requirements under Item 7 of "A. Completing the

Application."

Psp Change Of Name Or Address Application Page 2