Transmittal Information Cable Video State Franchise {GAVFL250}

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 TR A N SMITT A L INFORM A TION GEORGI A CABLE/VIDEO STATE FRANCHISE IMPORTANT Remember to include your e - mail address when completing this transmittal form. Providing your e - mail address allows us to notify you via e - mail when we receive your filing and when we take action on your filing. Please enter your e - mail address on the line below. Thank you. E - Mail: NOTICE TO A PPLIC A N T: PRINT PL A I NLY OR TYPE RE M A INDER OF THIS FORM 1. Company Name of Cable/Video Service Provider ( List exactly as it appears in documents) Mailing Address 2. Name and title of person filing state franchise application ( c ertificate w ill be mailed to this person at address belo w . ) Telephone Number Address City State Zip Code 3. Mail the following items to the Secretary of State at the above address: 1) This transmittal form; 2) Application for State Franchise (Form GAVFL001) ; 3) A valid Certificate of Existence or Certificate of Authority , if applicable ; and 4 ) Filing fee of $ 5 00.00 pa y able to Secretary of State. Filing fees are N O N - refundable. Signature of Authorized Person : Date: Print Name : Request certificates and obtain entity information via the Internet: sos.georgia.gov/corporations FORM GAVFL250 (Rev . 10/2018 ) American LegalNet, Inc. www.FormsWorkFlow.com