Free Microsoft Word - wats_app_010809 - Indiana

Print Form

VERIFIED APPLICATION FOR ISSUANCE OF A CERTIFICATE OF TERRITORIAL AUTHORITY TO RESELL WIDE AREA TELEPHONE SERVICE AND/OR INTEREXCHANGE INTRASTATE TELECOMMUNICATIONS SERVICES WITHIN THE STATE OF INDIANA (As addressed by Cause No. 38149)
State Form 50491 (R2/1-09)

INDIANA UTILITY REGULATORY COMMISSION

(Instructions: Complete all blanks and include supporting documentation as attachments to this form.) To the Telecommunications Division of the Indiana Utility Regulatory Commission ("IURC"):________________________________________________________ ("Applicant") hereby applies to the Indiana Utility Regulatory Commission for a Certificate of Territorial Authority ("CTA") to resell wide area telephone services and/or interexchange, intrastate telecommunications services in Indiana, and represents that: 1. Applicant's principal name (including any "doing business as (d/b/a)" names) as authorized by the Indiana Secretary of State is: (Attach a copy of approval Certificate of Authority from Indiana Secretary of State.) (a) Principal Name: ________________________________________________________ (b) d/b/a Name: __________________________________________________________ 2. Applicant's principal address, telephone number, fax numbers and regulatory contact person for purposes of these proceedings and any subsequent IURC communications is: (a) Address: ________________________________________________________ (b)Telephone Number: __________________________________ FAX Number: _________________________________________ E-mail Address: ____________________________________ (c) Contact Person & Title: ___________________________________________ 3. Applicant requests a CTA for the following geographic area: (a) Geographic area: ________________________________________________ (i.e., "State of Indiana") 4. The principal name, address, telephone number, fax number of Applicant's parent company is: (a) Company Name: _________________________________________________ (b)Address: ________________________________________________________

(c) Telephone Number: _____________________________________ FAX Number: _____________________________________________ Applicant further represents that it: A. Has the financial, managerial, and technical ability to provide the services for which it hereby requests a CTA. B. Will comply with Indiana laws and the Commission's regulation and orders of generic application concerning the resale of WATS and/or interexchange, intrastate telecommunications services in Indiana which do not constitute an unlawful barrier to entry into the telecommunications marketplace for such service; C. Will pay the public utility fee required by I.C. 8-1-6; D. Will advise any LEC of the nature of Applicant's use of that LEC's facilities and pay such LEC the lawful Commission approved tariffed rates for such services; and, E. Will notify the Commission within thirty (30) days of any changed or additional name under which it will provide services, and any change of address of Applicant's principal business address or change in name of persons authorized to receive notice on behalf of the Applicant. VERIFICATION I affirm under the penalties of perjury that the foregoing representations are true.

___________________________________________________________________ Officers Name & Title (printed) Signature & Date (month, day, year): _____________________________ Telephone Number: _____________________________ ________________________________________________________________________ IURC Staff Use Only: CERTIFICATE OF TERRITORIAL AUTHORITY A Certificate of Territorial Authority to provide public utility service (as defined by I.C. 8-1-2-1) and telephone service as a telephone company (as those terms are defined by I.C. 8-1-2-88) as set forth in the foregoing application is hereby issued to the Applicant discussed herein to resell wide area telephone services and/or interexchange, intrastate telecommunications services in accordance with and subject to the provisions of the Indiana Utility Regulatory Commission's Orders in Cause No. 38149, and the process established by the Seventh Supplemental Order issued on January 14, 1998, in that Cause. Acknowledged by the IURC: _____________________ CTA No.:________________ Date (month, day, year): _______________________________________________________________