"Modification of Boundaries of Video Service Provider" - Arkansas

Modification of Boundaries of Video Service Provider is a legal document that was released by the Arkansas Secretary of State - a government authority operating within Arkansas.

Form Details:

  • Released on November 1, 2018;
  • The latest edition currently provided by the Arkansas Secretary of State;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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

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Download "Modification of Boundaries of Video Service Provider" - Arkansas

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Arkansas Secretary of State
1401 W. Capitol, Suite 250, Little Rock, AR 72201
John Thurston
501-682-3409 • www.sos.arkansas.gov
MODIFICATION OF BOUNDARIES OF VIDEO SERVICE PROVIDER
1. Video Service Provider:
2. Date Certificate of Franchise Authority Was Issued by Secretary of State:
3. Please identify below, political subdivisions and/or parts of political subdivisions which have been added or removed from the
service area in which the franchise holder provides video service. If the service area includes an entire county, please list all political
subdivisions within the county.
Added Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area includes
only a portion of the county, please describe the area.)
Removed Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area
includes only a portion of the county, please describe the area.)
Added Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or
town, please describe the area)
Removed Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or
town, please describe the area)
4. Date Franchise Holder intends to begin providing video service for modified areas listed above:
AFFIDAVIT
I, the undersigned, being first duly sworn, state that I am an officer, general partner, or managing member of the Video Service
Provider listed above, that I have read the above document and know its contents and that the facts stated therein are true and correct:
Signature
Title
Printed Name
Date
State of Arkansas
County of
On this the
day of
, 20
, before me,
, the undersigned notary,
personally appeared
known to me (satisfactorily proven) to be the person whose name is
subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Notary Public:
[Notary Seal]
My Commission Expires:
Rev. 11/18
Filing Fee $100.00, payable to Arkansas Secretary of State
Arkansas Secretary of State
1401 W. Capitol, Suite 250, Little Rock, AR 72201
John Thurston
501-682-3409 • www.sos.arkansas.gov
MODIFICATION OF BOUNDARIES OF VIDEO SERVICE PROVIDER
1. Video Service Provider:
2. Date Certificate of Franchise Authority Was Issued by Secretary of State:
3. Please identify below, political subdivisions and/or parts of political subdivisions which have been added or removed from the
service area in which the franchise holder provides video service. If the service area includes an entire county, please list all political
subdivisions within the county.
Added Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area includes
only a portion of the county, please describe the area.)
Removed Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area
includes only a portion of the county, please describe the area.)
Added Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or
town, please describe the area)
Removed Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or
town, please describe the area)
4. Date Franchise Holder intends to begin providing video service for modified areas listed above:
AFFIDAVIT
I, the undersigned, being first duly sworn, state that I am an officer, general partner, or managing member of the Video Service
Provider listed above, that I have read the above document and know its contents and that the facts stated therein are true and correct:
Signature
Title
Printed Name
Date
State of Arkansas
County of
On this the
day of
, 20
, before me,
, the undersigned notary,
personally appeared
known to me (satisfactorily proven) to be the person whose name is
subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Notary Public:
[Notary Seal]
My Commission Expires:
Rev. 11/18
Filing Fee $100.00, payable to Arkansas Secretary of State