ROSS MILLER Secretary of State 204 North Carson Street, Suite 4 Carson City, Nevada 89701-4520 (775) 684-5708 Website: www.nvsos.gov Application for Certificate of Authority and Affidavit (PURSUANT TO NRS CHAPTER 711) Page 1 USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 1. Name of Applicant: 2. Following is a description of each service area designated by the applicant in which the applicant intends to provide video service: (mark box to confirm) Attached is an 8 1/2" x 11" map of each such service area that shows the territorial boundaries of each local government located, in whole or in part, within the service area. 3. The location of the principal place of business of the applicant is: Street Address City State Zip Code Nevada Secretary of State ACOA Page 1 Revised: 4-30-09 American LegalNet, Inc. www.FormsWorkFlow.com ROSS MILLER Secretary of State 204 North Carson Street, Suite 4 Carson City, Nevada 89701-4520 (775) 684-5708 Website: www.nvsos.gov Application for Certificate of Authority and Affidavit (PURSUANT TO NRS CHAPTER 711) Page 2 USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 4. Application Fee:* Based upon the information that has been set forth in section 2 of this form, the application fee of this Certificate of Authority and Affidavit is: $250.00 - Service area located entirely within the territorial boundaries of a county whose population is less than 50,000. $500.00 - Service area located in whole or in part within the territorial boundaries of a county whose population is 50,000 or more but less than 100,000. $1,000.00 - Service area located in whole or in part within a county whose population is 100,000 or more. 5. Certificate Fee:* Based upon the information that has been set forth in section 2 of this form or by election of the statewide certificate, the certificate fee of this Certificate of Authority and Affidavit is: (a) $250.00 - Service area located entirely within the territorial boundaries of a town, township or city whose population is less than 1,000, regardless of the population of the county. (b) $2,500.00 - Service area located entirely within the territorial boundaries of a town, township or city whose population is 1,000 or more but less than 50,000, regardless of the population of the county. (c) $2,500.00 - Service area located entirely within the territorial boundaries of a county whose population is less than 50,000, unless the provisions of 5(a) or 5(b) apply. (d) $15,000.00 - Service area located in whole or in part within the territorial boundaries of a county whose population is 50,000 or more but less than 100,000, unless the provisions of 5(a), 5(b) or 5(e) apply. (e) $25,000.00 - for a Service area located in whole or in part within the territorial boundaries of a county whose population is 100,000 or more unless the provisions of 5(a) or 5(b) apply. or $25,000.00 - Certificate of Authority that permits, but does not require, applicant to provide video service within one or more service areas located anywhere in this state as designated in this application and affidavit. *Required Filing Fee = Application Fee + Certificate Fee Nevada Secretary of State ACOA Page 2 Revised: 4-30-09 American LegalNet, Inc. www.FormsWorkFlow.com ROSS MILLER Secretary of State 204 North Carson Street, Suite 4 Carson City, Nevada 89701-4520 (775) 684-5708 Website: www.nvsos.gov Application for Certificate of Authority and Affidavit (PURSUANT TO NRS CHAPTER 711) Page 3 USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 6. The names of the principal executive officers or general partners of the applicant are: (if more than four, please attach an 8 1/2" x 11" plain sheet of paper and continue listing each name and title) Name Title Name Title Name Title Name Title 7. Certifications and Signature of the Applicant: The applicant hereby agrees to comply with all the applicable federal and state laws and regulations; all generally applicable, nondiscriminatory local laws regarding the use and occupation of any public right-of-way or highway in the construction, operation, maintenance and repair of a video service network, including, without limitation, any local laws, enacted pursuant to the police powers of the local government in which the video service network is located; and has filed or will timely file with the Federal Communications Commission all the forms required by that agency before offering video service. X Name Signature of Applicant State of County of Subscribed and sworn on 20 , by Notary Signature Nevada Secretary of State ACOA Page 3 Revised: 4-30-09 American LegalNet, Inc. www.FormsWorkFlow.com