Form GAVFL001 "Application for State Franchise to Provide Cable and/or Video Service" - Georgia (United States)

What Is Form GAVFL001?

This is a legal form that was released by the Georgia Secretary of State - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the Georgia Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form GAVFL001 by clicking the link below or browse more documents and templates provided by the Georgia Secretary of State.

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Download Form GAVFL001 "Application for State Franchise to Provide Cable and/or Video Service" - Georgia (United States)

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OFFICE OF SECRETARY OF STATE
CORPORATIONS DIVISION
313 West Tower
2 Martin Luther King Jr. Dr.
Atlanta, GA 30334
(404) 656-2817
sos.georgia.gov/corporations
Secretary of State
APPLICATION FOR STATE FRANCHISE
TO PROVIDE CABLE AND/OR VIDEO SERVICE
Personally appeared before me the undersigned being duly sworn according to law, and
swears to the facts contained in this application. Pursuant to O.C.G.A. § 36-76-4, as
amended, the undersigned hereby applies for a state franchise to provide cable service
and/or video service in the State of Georgia:
1. The name of the applicant is:
2. The principal place of business of the applicant is:
The mailing address of the applicant is:
3. The principal executive officer(s) of the applicant are:
(Attach additional sheet if necessary.)
Name
Title
Address
4. Subscribers may make payment or return equipment in accordance with the subscriber
agreement to the following locations of the applicant or its affiliates.
OFFICE OF SECRETARY OF STATE
CORPORATIONS DIVISION
313 West Tower
2 Martin Luther King Jr. Dr.
Atlanta, GA 30334
(404) 656-2817
sos.georgia.gov/corporations
Secretary of State
APPLICATION FOR STATE FRANCHISE
TO PROVIDE CABLE AND/OR VIDEO SERVICE
Personally appeared before me the undersigned being duly sworn according to law, and
swears to the facts contained in this application. Pursuant to O.C.G.A. § 36-76-4, as
amended, the undersigned hereby applies for a state franchise to provide cable service
and/or video service in the State of Georgia:
1. The name of the applicant is:
2. The principal place of business of the applicant is:
The mailing address of the applicant is:
3. The principal executive officer(s) of the applicant are:
(Attach additional sheet if necessary.)
Name
Title
Address
4. Subscribers may make payment or return equipment in accordance with the subscriber
agreement to the following locations of the applicant or its affiliates.
5. Pursuant to O.C.G.A. § 36-76-4(c)(2), the applicant’s service areas are described below
and/or on the attached 8.5” x 11 map labeled as “Exhibit A”:
Service Area Description:
6. The applicant certifies that the following affected counties and municipalities have been
provided with a copy of this application pursuant to O.C.G.A 36-76-4 (a), and with notice
acknowledging its right to designate a franchise fee pursuant to O.C.G.A. 36-76-6.
7. This applicant:
Has wireline facilities located in the public right of way as of January 1, 2008.
Does not have wireline facilities located in the public right of way as of January 1,
2008.
8. The applicant certifies that it is authorized to conduct business in the State of Georgia.
[Applicants that did not have wireline facilities located in the public right of way as of January
1, 2008 must provide a Certificate of Existence or Certificate of Authority from the
Corporations Division of the Georgia Secretary of State’s Office with this application.]
9. The applicant certifies that it has satisfactory financial and technical capability to provide
cable and/or video service. A description of such capabilities is attached hereto as required
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GAVFL001
(Rev. 6/2019)
by O.C.G.A. 36-76-4(c)(4).
[This requirement does not apply to applicants with existing wireline
services as of January 1, 2008.]
10. The applicant agrees to comply will all applicable federal and state laws and regulations,
including municipal and county ordinances and regulations regarding the placement and
maintenance of facilities in the public right of way that are generally applicable to all users
of the public right of way and specifically including O.C.G.A. Chapter 9 of Title 25, the
‘Georgia Utility Facility Protection Act.’
11. The applicant agrees to pay to each affected local governing authority a franchise fee
established by such local governing authority which shall not exceed the maximum
percentage rate permitted in 47 U.S.C. Section 542(b) of the applicant’s gross revenues
received from the provision of cable service or video service to subscribers located within
the service area. Such franchise fee shall be paid directly to each affected local governing
authority within 30 days after the last day of each calendar quarter.
Submitted this ______ day of __________________, 20____.
Signature of Officer/General Partner
Print Name
Title
Address
Telephone Number
Email Address
State of
County of
Sworn to and subscribed before me this_____ day of ________________, 20____.
Notary Public Signature
My Commission expires:
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GAVFL001
(Rev. 6/2019)
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