N.C. Admin. Code tit. 04, ch. 11, ch. 14, app 11 R14
APPLICATION FOR SPECIAL CERTIFICATE TO OFFER SHARED AND/OR RESOLD (STS) TELEPHONE SERVICE
STS SPECIAL CERTIFICATE NO. ____
Note: To apply for Special Certification, Applicant must submit a filing fee of $25.00 and the typed
original and 8 copies of this document to the Commission at the following address:
Chief Clerk
North Carolina Utilities Commission
4325 Mail Service Center
Raleigh, NC 27699-4325
DATE OF APPLICATION ________________
APPLICANT
_________________________________________________________________________________
(NAME)
_________________________________________________________________________________
(STREET)
_________________________________________________________________________________
(CITY, STATE, ZIP)
TELEPHONE () ___________
ADDRESS AND DESCRIPTION OF PREMISES TO BE SERVED AND SERVICES TO BE OFFERED: (A map may be attached)
REPRESENTATIVE TO WHOM COMPLAINTS SHOULD BE ADDRESSED
_________________________________________________________________________________
(NAME)
_________________________________________________________________________________
(STREET)
_________________________________________________________________________________
(CITY, STATE, ZIP)
TELEPHONE ()___________________
As the provider of resold and/or shared service, I certify that I have read and agree to abide by the Rules in Chapter 14 of the North Carolina Utilities Commission attached as Appendix A to this Application.
___________________Date
Signature of Applicant__________________________
Title________________________________________
VERIFICATION
STATE OF _________ COUNTY OF _______________
The above-named _________, personally appeared before me this day and, being first duly sworn, says that the facts stated in the foregoing application and any exhibits, documents, and statements thereto attached are true as he verily believes.
WITNESS my hand and notarial seal, this ____ day of _____, 19__.
________________________
Notary Public
My Commission expires: __________
N.C. Admin. Code tit. 04, ch. 11, ch. 14, app 11 R14