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Federal Communications Commission Washington, D.C. 20554

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FCC FORM 1275 CERTIFICATION FOR OPEN VIDEO SYSTEMS

Company

Name:

Contact

Person:

Mailing

Address:

City:

IState:
IFax Number:

IZip Code ,

Phone Number:

Yes 1. If you are a cable operator applying for certification within your cable franchise area, are you qualified to operate an open video system under 47 C.F.R. § 76.1501 ? ? Do you agree to comply and to remain in compliance with each of the Commission's regulations in 47 C.F .R. §§ 76.1503, 76.1504, 76.1506(m), 76.1508, 76.1509, and 76.1513? 3. Do you agree to comply with the Commission's notice and enrollment requirements Tor unaffiliated video programming providers? 4. If applicable, do you agree to file changes to your cost allocation 60 days before the commencement of service? manual at least

No

N/A

, .t:>rovide a general description of the anticipated communities or areas to be served upon completion of the system. .!c

f

2. Anticipated 4. If Switched
Number

Digital Capacity. Digital, Anticipated
Input -Ports:

Anticipated

of Channel

WILLFUL

FALSE STATEMENTS

MADE ON THIS FORM ARE PUNISHABLE 1001), AND/OR FORFEITURE

BY FINE AND/OR according

IMPRISONMENT 503) avail; to the most recent information

(U.S. CODE TITLE 18, SECTION To the best of my knowledge Name: --I

(U.S. CODE, TITLE 47, SECTION

and belief, the representations

made herein are accurate Signature: Date:

FCC Form August

1275 1996

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