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STATE OF SOUTH CAROLINA SECRETARY OF STATE

APPLICATION FOR A STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY
Pursuant to state law, a person or entity seeking to provide cable or video service must have a certificate of franchise authority, either an existing certificate issued by a local government under prior law, or upon expiration of that certificate issued by a local government, a state-issued certificate of franchise authority issued by the Secretary of State under S.C. Code of Laws §58-12-310(B).

TYPE OR PRINT CLEARLY WITH BLACK INK

Pursuant to S.C. Code Section 58-12-310, the undersigned hereby applies for authorization to provide cable or video service in the state of South Carolina. 1. The name of the applicant is

2. 3.

The applicant is providing

Cable Service

OR



Video Service

The street address of the applicant is
Street Address City County State Zip Code

The mailing address of the applicant is

4.

The municipalities and unincorporated areas of counties that are proposed to be served by the applicant are to be described in the accompanying Affidavit in Support of State-Issued Certificate of Franchise Authority. For each of the municipalities and unincorporated areas of counties so described, provide the name, address and telephone number for the person to whom the Notice of Application for a State-Issued Certificate of Franchise Authority should be provided.
Expiration Date of Current Franchise (if applicable)

Municipality/Area

Name & Title

Address

Telephone No.

5.

This application is accompanied by an affidavit signed by an officer or general partner of the applicant and fee as required by S.C. Code Section 58-12-310(B).

Date
Officer/General Partner's Signature

Type or Print Name

Address

Telephone Number

APPLICATION FOR A CERTIFICATE OF FRANCHISE AUTHORITY

Form Revised by South Carolina Secretary of State May 2008

AFFIDAVIT IN SUPPORT OF APPLICATION FOR STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY

PERSONALLY appeared before me the undersigned who being duly sworn according to law,
deposes and says on oath: My name is of and my title/position is_______ .This affidavit is

based upon my personal knowledge of the facts contained in the Application for State-Issued Certificate of Franchise Authority and this affidavit. I certify and affirm that all such facts are true and correct. I affirm that the applicant agrees to comply with all applicable federal and state laws and regulations. In this application the applicant seeks to provide cable or video services in the following areas:

(Written description of the municipalities and unincorporated areas of the counties to be served in whole or in part. A map or other graphic representation may supplement, but not substitute for, the written description.)

The principal place of business for the applicant is located at

The principal executive officers of the applicant are:
Name & Title Address Telephone No.

Dated this

day of

,

.

SWORN to and subscribed before me, this day of ,
Officer/General Partner's Signature

Type or Print Name

Notary Public for My Commission Expires:

Address

Telephone Number

FILING INSTRUCTIONS

1. 2. 3.

Two copies of this form (application and affidavit), the original and either a duplicate original or conformed copy, must be filed. If the space in this form is insufficient, please attach additional sheets containing a reference to the appropriate paragraph in this form. Filing Fee (payable to the Secretary of State at the time of filing this document) - $110.00 Return to: Secretary of State Attn: Wendy B. Holcombe Post Office Box 11350 Columbia, SC 29211

SPECIAL NOTES PURSUANT TO STATE LAW, A PERSON OR ENTITY SEEKING TO PROVIDE CABLE OR VIDEO SERVICE MUST HAVE A CERTIFICATE OF FRANCHISE AUTHORITY, EITHER AN EXISTING CERTIFICATE ISSUED BY A LOCAL GOVERNMENT UNDER PRIOR LAW, OR UPON EXPIRATION OF THAT CERTIFICATE ISSUED BY A LOCAL GOVERNMENT, A STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY ISSUED BY THE SECRETARY OF STATE UNDER S.C. CODE OF LAWS §58-12-310(B). PURSUANT TO S.C. CODE §58-12-310(B)(3), A HOLDER OF A STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY MUST BEGIN TO DEPLOY SERVICE IN EACH OF THE MUNICIPALITIES AND IN EACH OF THE UNINCORPORATED AREAS OF COUNTIES DESCRIBED IN THE APPLICATION WITHIN ONE YEAR FROM THE DATE OF ISSUANCE OR THE CERTIFICATE BECOMES NULL AND VOID. PURSUANT TO S.C. CODE §58-12-310(K), THE HOLDER OF A STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY MUST GIVE WRITTEN NOTIFICATION TO A MUNICIPALITY OR COUNTY OF THE DATE IT WILL ACTUALLY BEGIN PROVIDING SERVICE IN ANY PART OF SUCH MUNICIPALITY OR COUNTY. S.C. CODE §58-12-360 PROVIDES THAT THE S.C. DEPARTMENT OF CONSUMER AFFAIRS MUST RECEIVE COMPLAINTS FROM CUSTOMERS OF COMPANIES WHICH HOLD A STATE-ISSUED CERTIFICATE OF FRANCHISE AUTHORITY IN ACCORDANCE WITH S.C. CODE §37-6-117. CONTACT INFORMATION FOR THE DEPARTMENT OF CONSUMER AFFAIRS MUST BE PRINTED ON THE CUSTOMER'S BILL.