Application For State Franchise To Provide Cable And Or Video Service {GAVFL001}

Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 313 West Tower 2 Martin Luther King Jr. Dr. Atlanta, GA 30334 (404) 656 - 2817 sos.georgia.gov/corporations APPLICATION FOR S TATE FRANCHISE TO PROVIDE CABLE AND/OR VIDEO SERVICE Personally appeared be f ore m e the undersigned being duly sworn accor d ing to law, and swears to the facts contained in this application. Pursuant to O.C.G.A. 247 36 - 76 - 4, as a m ended, the unders i gned hereby applies for a state franchise to provide cable service and/or video service in the State of Georgia: 1. The na m e of the applicant is: 2. The principal place of busi n ess of t h e applicant is: The mailing address of the applicant is: 3. The principal exec u tive o fficer(s) of the applicant are: (Attach additional sheet if necessary . ) Name Title Address 4. Subscribers m ay make pay m ent or return eq ui pment in accordance with the subscri b er a gree m ent to the f ollowi n g locations o f the appli ca nt or its a ffi liat e s. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 GAVFL001 (Rev. 6 /2019 ) 5 . Pursuant to O.C.G.A. 247 36 - 76 - e rvice areas are described below and/or on the attached m Service Area Description: 6. The applicant certifies that the following affected counties and m unicipalities have been provided with a copy of this application pursuant to O.C.G.A 36 - 76 - 4 (a), and with notice acknowledging its right to de s i gnate a fra n chise fee pursuant to O.C.G.A. 36 - 76 - 6. 7 . This applic a nt: Has wireline f a c iliti e s loc a t e d in the public right of way as of January 1, 2008. Does not have wireli n e f acilities lo c ated in the pu b lic right of way as of January 1, 2008. 8 . The applicant certifies that it is authorized to condu c t business in the S t ate of Georgia. [Applicant s that did not have wireline facilities located in the public right of way as of January 1, 2008 m u st provide a Certi f ic a t e o f Existence or Certificate of Authority f rom the p plic a t ion . ] 9 . The applic a nt ce r ti f ies that it has satisfactory f i na n cial and tech ni cal capability to provide cable and/or video s er vice. A description of such capabilities is attached hereto as required American LegalNet, Inc. www.FormsWorkFlow.com Page 3 GAVFL001 (Rev. 6 /2019 ) by O.C.G.A. 36 - 76 - 4(c)(4). [This requirement d o es n ot apply to applicants with exi s ting wireline services as of January 1, 2008.] 10. The applica n t agrees to co m ply will all a p plica b le federal and state laws and regulations, i n cluding municipal and county ordinances and regulations regarding the pl a cement and m aintenance of f acilities in the public right of way that are generally applicable to all use r s o f the public right of way and speci f i cally i n cluding O.C.G.A. Chapter 9 of Title 2 5, the r gia Utility Facility Protecti o n Act . 11. The a p plica n t agr e es to pay to each affect e d local governing authority a franchise fee esta b lished by such local governing authority which shall not exceed the m ax i m u m percenta g e rate per m itted in 47 U . S.C. Section 54 2 (b) of the ap p lica n g ro s s revenues received fr o m the provi s i on of cable service or video service to subscribers l o cated within t h e service area. Such franchise fee shall be paid directly to each affected local go v erning a u thority within 30 days after the last day of each calendar quarter. Submit ted this day of , 20 . Signature of Officer/General Partner Print Name Title Address Telephone Number Email Address State of County of Sworn to and subscribed before m e this day of , 20. Notary Public Signature My Com m ission expires : American LegalNet, Inc. www.FormsWorkFlow.com