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APPLICATION FOR A CERTIFICATE OF TERRITORIAL AUTHORITY FOR COMMUNICATIONS SERVICE PROVIDERS
State Form 52648 (R2 / 5-09)

INDIANA UTILITY REGULATORY COMMISSION

Applicants are required to file an original and five paper copies and an electronic copy in PDF format on disk.

Cause number __________________ (IURC use only)
PURSUANT TO IC 8-1-32.5-4, A "COMMUNICATIONS SERVICE PROVIDER" MEANS A PERSON OR ENTITY THAT OFFERS COMMUNICATIONS SERVICE TO CUSTOMERS IN INDIANA, WITHOUT REGARD TO THE TECHNOLOGY OR MEDIUM USED BY THE PERSON OR ENTITY TO PROVIDE THE COMMUNICATIONS SERVICE. THE TERM INCLUDES A PROVIDER OF COMMERCIAL MOBILE RADIO SERVICE (AS DEFINED IN 47 U.S.C. 332). List each type of Communications Service which applicant proposes to offer in Indiana: TELECOMMUNICATIONS SERVICE AS DEFINED IN 47 U.S.C. 153(46) ____________________________________________________________________________________ ____________________________________________________________________ Please list each type of service, such as facilities-based local exchange; bundled resale of local exchange; commercial mobile radio service; interexchange; operator services or other. INFORMATION SERVICE AS DEFINED IN 153(20), WITHOUT REGARD TO THE TECHNOLOGY OR MEDIUM USED TO PROVIDE THE COMMUNICATIONS SERVICE. ____________________________________________________________________________________ ____________________________________________________________________ Please list each type of service, such as internet protocol enabled services; broadband service; advanced service (as defined in 47 CFR 51.5); or other. VIDEO SERVICE AS DEFINED IN IC 8-1-34-14 (a Video Service Provider which does not have a current Video Service Franchise for the service area described below must also obtain a state issued video franchise as specified in IC 8-1-34-16)

I.

Applicant Contact Information

A. Legal name of company: ____________________________________________________________ B. Name(s) under which the company will be marketing services in Indiana:
(Company names, including any "doing business as" names, must be registered with Indiana Secretary of State)

____________________________________________________________________________ ____________________________________________________________________________
C. Company address: ____________________________________________________________________________________

_____________________________________________________________________
Main telephone number: _____________________ Fax number: ___________________________ E-mail address: ______________________________________________ Website address: _____________________________________________

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D. Parent company's legal name, address, and telephone number (if applicable): ____________________________________________________________________________________

_____________________________________________________________________
E. Name, title, and other contact information of company's contact person for ongoing communications with the commission (including regulatory affairs and/or customer service information): Name and title ____________________________________________________________________ Telephone number: ________________________ Fax number: ___________________________ Mailing address: ___________________________________________________________________ Email address: _______________________________________ F. Name, title, and other contact information of attorney or contact person for this application, if different from E. above: Name and title ____________________________________________________________________ Telephone number: ________________________ Fax number: ___________________________ Mailing address: ___________________________________________________________________ E-mail address: _______________________________________________

II.

Service Information

(add additional sheets if necessary) A. Please describe the area(s) for which the applicant seeks authority.

_____________________________________________________________________________ _____________________________________________________________________________
B. Please provide a description of each service area in Indiana in which the applicant initially proposes to offer communications service (i.e., county, city or rate center). If the applicant is a CMRS provider, please list the MTA(s) in Indiana for which the applicant is or will be licensed by the FCC. ____________________________________________________________________________________ ____________________________________________________________________________________ C. Please provide a description of each type of communications service that the provider proposes to offer in each of the service areas identified in II B. above. The services listed should be consistent with the services marked at the top of Page 1. ____________________________________________________________________________________ ____________________________________________________________________________________ D. For each type of service identified in C, please list whether the communications service will be offered to residential customers, business customers or both. If applicant is proposing to offer Video Service, will the service be authorized through a state franchise or a local franchise? If authorized through a local franchise, please specify the issuing franchise authority and provide the expiration date. ____________________________________________________________________________________ ____________________________________________________________________________________ E. Please provide an estimated date of deployment (year and quarter) for each service area and each service type within that area for which the applicant seeks authority. The services listed should be consistent with the services marked at the top of Page 1. ____________________________________________________________________________________ ____________________________________________________________________________________

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F. Will applicant offer stand alone basic telecommunications service for a flat monthly rate pursuant to IC 8-1-2.6-0.1? ____________________________________________________________________________________ G. Does the applicant seek authorization to provide facilities-based local exchange? ________________ H. Does the applicant seek authorization to offer interexchange services only? ____________________ I. J. Does the applicant intend to offer commercial mobile radio service only? _______________________ Is applicant a wholesale or a retail communications service provider? _________________________

K. Will the applicant operate as a Local Cooperative Corporation pursuant to IC 8-1-17-3?
____________________________________________________________________________________________

If yes, please submit 3 original articles of incorporation as required by IC 8-1-17-5 et seq.1

L. Please list other states in which applicant is authorized to provide communications services and the types of services offered. ____________________________________________________________________________________ ____________________________________________________________________________________

III.

Additional Requirements

Applicant further represents that it will: · Comply with Indiana law (including but not limited to Title 8 of the IC) and IURC regulations (170 IAC 7) and applicable current and future Orders of the IURC.2 · File intrastate access tariffs, concurrences, and exceptions pursuant to the Commission's filing procedures and provide informational copies of interstate access tariffs. · Provide the Commission with current and updated/corrected hyperlinks to the company's intrastate and interstate access tariffs, concurrences, and exceptions. · Notify the Commission of any change in the legal name, address, control or status of the CTA, or service area, pursuant to IC 8-2-32.5-12 using the CSP Notice of Change Form prescribed by the Commission. Such notification of change shall be provided to the Commission thirty (30) days prior to the occurrence of the change. · Upon request, provide any other information the Commission is authorized to collect from a communications service provider under state or federal law pursuant to IC 8-12.6-13-9(E). · Applicant represents that it will, at the time requested by the commission, provide an annual report concerning communications services offered in each service area (county and zip code) in Indiana as required by IC 8-1-2.6-13(d)(9)((C) Note: This does not apply to CMRS providers.

The Commission is required to provide notice of CTA applications of local cooperative corporations to each facilities-based local exchange carrier operating in territory contiguous to the area in which the cooperative corporation proposes to render telephone service pursuant to IC 8-1-17-5(d) 2 Telecommunications Service Providers and Video Service Providers are subject to enforcement remedies for prohibited actions pursuant to IC 8-1-29.5.

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IV.

Attachments

The following information must be included with this application: 1. Applicant's certification from the Indiana Secretary of State authorizing the applicant to do business within the State of Indiana. 2. Information demonstrating the financial, managerial and technical ability to provide each communication service identified in the application. a. The applicant's most recent financial statement or balance sheet or that of the parent company if separate Indiana operations have not yet been established. b. Biographies of the applicant's corporate officers responsible for Indiana indicating managerial and technical qualifications. (Attachment 2a and 2b are not required for CMRS providers.) 3. A statement signed under penalty of perjury by an officer or another person authorized to bind the applicant (see attached affidavit). Although an evidentiary hearing before the Commission is not required, the Commission shall hold an evidentiary hearing, if one is requested pursuant to IC 8-1-32.5-9(a). Any hearing shall follow the statutory provisions of IC 8-1-32.5-9(b). 3

V.

Application Verification

I affirm under the penalties of perjury that the above representations made in this application are true. (Must be signed by an officer of the company) ________________________________________________________________________ Signature and date (month, day, year)

_________________________________________________________________________ Name and title (printed or typed)

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The FCC determines market entry of CMRS providers pursuant to 47 CFR Chapter 1 Part 13.

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VI.

Affidavit4

As an authorized corporate officer or person authorized to bind ____________________________________________________ (applicant/company name), I, ______________________________________ (print name), affirm under penalty of perjury that: a) the applicant has filed or will timely file with the Federal Communications Commission ("FCC") all forms required by the FCC; b) the applicant agrees to comply with customer notification requirements of the Commission pursuant to IC 8-1-32.5-6(b)(3)(B) and 8-1-32.5-11(b) (not applicable to CMRS providers per IC 8-1-32.5-11(b)); c) the applicant (including CMRS providers5) agrees to update the information provided in the application on a regular basis pursuant to IC 8-1-32.5-12; d) the applicant agrees to notify the Commission when the applicant commences offering communications service in each service area identified in the application; e) the applicant agrees to pay any lawful rate or charge for switched and special access services, as required under any: · · applicable interconnection agreement; or lawful tariff or order approved or issued by a regulatory body having jurisdiction. f) the applicant agrees to report, at the time requested by the Commission, information required under IC 8-1-2.6-13(d)(9) et seq.; and g) applicant further represents that it will provide an annual report concerning communications services offered in each service area (county, zip code and census tract) in Indiana as required by IC 8-1-2.6-13(d)(9)(C). (Not applicable to CMRS providers per IC 8-12.6-13(d)(9).

_____________________________________________
Signature

_____________________________________________
Title

_____________________________________________
Date (month, day, year)

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See IC 8-1-32.5-6(b)(3). There is an exception in IC 8-1-32.5-12-6 to the information that CMRS providers must provide. This exception does not apply to the other subsections in 8-1-32.5-12.

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Subscribed and sworn to before me, a Notary Public, this ______ day of _______________, A.D. 20____ _____________________________________ Signature _____________________________________ Printed name My commission expires: My county of residence: ____________________ ____________________

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