Application To Register As A Video Service Provider

Arkansas Secretary of State Mark Martin State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov Business & Commercial Services, 1401 W. Capitol, Suite 250, Little Rock, AR 72201 APPLICATION TO REGISTER AS A VIDEO SERVICE PROVIDER 1. Applicant's Name: 2. Address of Principal Place of Business in Arkansas: City: E-mail: 3. Applicant Authorized to Do Business in Arkansas: and Type of Entity: 4. Names of Principal Executive Officers: Titles of Principal Executive Officers: State: Phone: Zip: Yes No If Yes, Please Provide Secretary of State Entity Filing Number 5. Applicant's Designated Arkansas Representative for Video Services: 6. Please identify on the second page of the application, all political subdivisions and/or parts of political subdivisions which constitute the service area in which the applicant intends to provide video service. If the service area includes an entire county, please list all political subdivisions within the county. 7. Date Applicant intends to begin providing video service for the areas listed on page 2 of this application: 8. Please verify the following by checking the necessary boxes: Applicant has filed with the Federal Communications Commission the applicable forms needed in advance of offering video service in this state. Applicant is legally, financially, and technically qualified to provide video service. Applicant has and maintains, with one (1) or more companies licensed to do business in Arkansas, comprehensive general liability insurance coverage and automobile liability insurance coverage (coverage of not less than one million dollars ($1,000,000) for one occurrence or incident), or Applicant has self-insurance in compliance with A.C.A. § 23-19-203 and A.C.A. § 27-19-207. AFFIDAVIT I, the undersigned, being first duly sworn, state that I am an officer, general partner, or managing member of the Video Service Provider listed above, that I have read the application, including the supplemental information on page 2, and know its contents and that the facts stated therein are true and correct: Signature Printed Name State of Arkansas County of On this the day of , 20 , before me, , the undersigned notary, Title Date personally appeared known to me (satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary Public: [Notary Seal] My Commission Expires: Rev. 5/13 Page 1 of 2 Filing Fee $1,500.00, payable to Arkansas Secretary of State American LegalNet, Inc. www.FormsWorkFlow.com Arkansas Secretary of State Mark Martin State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov Business & Commercial Services, 1401 W. Capitol, Suite 250, Little Rock, AR 72201 6. Political subdivisions and/or parts of political subdivisions: Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area includes only a portion of the county, please describe the area.) Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or town, please describe the area.) Rev. 5/13 Page 2 of 2 Filing Fee $1,500.00, payable to Arkansas Secretary of State American LegalNet, Inc. www.FormsWorkFlow.com