VSP APPLICATION AND AFFIDAVIT.PDF

APPLICATION AND AFFIDAVIT FOR UNIFORM VIDEO SERVICE LICENSE
(Pursuant to Title 11, Chapter 14, Arizona Revised Statutes)
Local Government: Maricopa County
I. Applicant:
Date: _________________
Applicant’s Name:
Principal Place of Business:
Phone: Address:
Maricopa County: State: Zip:
Type of Entity: Jurisdiction of Formation: Email:
II. Applicant's principal executive officers or general partners:
Name: ________________________________ Title: ___________________________________
Address: _________________________________________________________________________
Name: ________________________________ Title: ___________________________________
Address: _________________________________________________________________________
Name: ________________________________ Title: ____________________________________
Address: _________________________________________________________________________
Name: ________________________________ Title: ____________________________________
Address: __________________________________________________________________________
Ill. Person(s) authorized to represent Applicant before Maricopa County:
Name: ________________________________ Title: ____________________________________
Address: _________________________________________________________________________
Phone: _________________ Fax: ___________________ Email: ___________________________
Name: ________________________________ Title: ____________________________________
Address: _________________________________________________________________________
Phone: _________________ Fax: ___________________ Email: ___________________________
Name: ________________________________ Title: ____________________________________
Address: _________________________________________________________________________
Phone: _________________ Fax: ___________________ Email: ___________________________
IV. Check one pursuant to Arizona Revised Statutes Section 11-1911(C)(4):
D Applicant is an Incumbent Cable Operator as provided in Arizona Revised
Statutes, Section 11-1901(13).
D Applicant is not an Incumbent Cable Operator. The date on which the Applicant
expects to provide Video Services in the Service Area identified on attached
Exhibit A is:
Date: ____________________
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V. For All Applications:
A. The term of the uniform video service license shall be (not to exceed ten years):
Years
B. Applicant agrees to pay all lawful fees and charges imposed by Maricopa County as
provided in Arizona Revised Statutes, Section 11-1914(8)(4).
C. Applicant agrees to notify Maricopa County in writing of changes to the information
provided in sections I, II, and III within thirty (30) days after the change occurs as
provided in Arizona Revised Statutes, Section 11-1914(8)(2).
D. Provide an exact description of the Service Area as set forth in Arizona Revised
Statutes, Section 11-1911(C)(5), as identified by a geographic information system
digital boundary meeting or exceeding national map accuracy standards .
Select one:
X The Service Area consists of all the territory within the Boundaries of Maricopa County:
X The Service Area consists of all the territory within the area described on attached Exhibit A.
Applicant Verification
On _________________, 20__ I NAME Signor OF SIGNOR, filed an Application and Affidavit for Video
Service License Agreement with the Clerk of the Maricopa County Board of Supervisors on behalf
of APPLICANT’S NAME. I verify under penalty of perjury that the information contained in the
application is true and correct.
Name and Title (printed):
Signature: I Da t e :
STATE OF ARIZONA )
) ss.
County of Maricopa )
SUBSCRIBED AND SWORN to before me, this ____ day of _____________, 20__, by
_________________________, personally appearing.
________________________________
Notary Public
My commission expires:
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Maricopa County Receipt
The foregoing Application and Affidavit for Uniform Video Service License was received by Maricopa
County this day of , 20_ ; at AM PM
______________________________________
By
______________________________________
Print Name
______________________________________
Title
______________________________________
Address
______________________________________
City, State, Zip Code
______________________________________
Phone
______________________________________
Fax
______________________________________
Email
______________________________________
Date
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Exhibit A
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