Free I1CollectionAgencyRegistrationtoNewEntityFilings - Louisiana


File Size: 47.0 kB
Pages: 2
Date: November 17, 2008
File Format: PDF
State: Louisiana
Category: Secretary of State
Author: MPhillips
Word Count: 321 Words, 2,034 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.sos.louisiana.gov/Portals/0/T100Application%20for%20cable%20&%20video%20franchise.pdf

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JAY DARDENNE SECRETARY OF STATE

STATE OF LOUISIANA SECRETARY OF STATE

Commercial (225) 925-4704 (225) 922-0435 Fax Administrative Services (225) 925-4704 (225) 925-4726 Fax Uniform Commercial Code (225) 922-1193 (225) 922-0452 Fax

TRANSMITTAL INFORMATION For All Business Filings

Business Name (List exactly as it appears in documents)

Name of person filing document (evidence of filing will be mailed to this person, at address below)

Address

City

State

Zip Code

Daytime phone number

Fax number

Email address

NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or bar roll number on the document.

Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125 Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809 Web Site Address: www.sos.louisiana.gov
SS984 Rev. 10/08

Jay Dardenne

Secretary of State

APPLICATION FOR A STATE CABLE & VIDEO FRANCHISE
(R.S. 45:1361)
Return to: Commercial Division P.O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.louisiana.gov

CHECK ONE: ( ) Original Filing

( ) Renewal

( ) Amendment

Company/Applicant Name organized under the laws of the state of ______________________, county/parish of __________________ hereby agrees to maintain insurance in an amount not less than one million dollars either through a policy of public liability insurance or through self-insurance. The applicant agrees to comply with all applicable federal and state laws and regulations. Street address of principal place of business:

Names of the principal executive officers:

List of municipalities and/or parishes to be served:
(An addendum may be attached for additional municipalities/parishes.)

To be signed by an officer or general partner

Title and Date

On this ____ day of _____________, 20___, before me, personally appeared ___________________________, to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed it as his/her free act and deed.