Application Cover Sheet
Section 5 Chapter 23 OL 2015 Application
OAR 860-200-0100
INSTRUCTIONS: Complete every section of this application. Attach required documents to complete the application. You
will be notified when the Commission receives your application, and again when the Commission has made a
determination on the application.
1. LEGAL N
AME OF APPLICANT:
As registered with the Oregon Secretary of State
App
licant’s address:
2. FIL
ING TYPE: Is this an Original submission? OR Amended submission?
Is there a separate communication for protected material? _____________
3. NAME AND ADDRESS OF PERSONS TO CONTACT FOR INFORMATION REGARDING THIS APPLICATION:
Applicant’s Representative:
Name:
Address:
Pho
ne number:
Email address:
Individual authorized to answer technical questions related to the application if different than the representative:
Name:
Address:
Phone number:
Email address:
4. DOCUMENTS INCLUDED IN THIS FILING: [refer to OAR 860-200-0100 through 860-200-0150 for all specific data
required with an original application] Please check items below.
App
lication Fee - $50,000.00
Confirmation that a copy of the application was sent to the Oregon Department of Revenue
Contact information for technical questions relating to PUC determination that the project is qualified
Certification from company-authorized representative that project meets all requirements for a qualified
project
Written commitment regarding use of third-parties
Maps of project service area depicting county and city names and boundaries for both,
_____ Paper and _____ Electronic
City and county contact information where project is or will be located
List of census blocks served or planned to be served by the project and associated census block household data
(Excel-readable format.)
________ Number of applicant’s residential broadband customers, existing and planned
Applicant’s most recently filed FCC Form 477 Part 1A and Part 6
________ A description of the applicant’s project sufficient to make a determination
PUC Form FM515 12/2015
