"Termination of Certificate of Franchise Authority for Video Service Provider" - Arkansas

Termination of Certificate of Franchise Authority for 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;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • 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.

ADVERTISEMENT
ADVERTISEMENT

Download "Termination of Certificate of Franchise Authority for Video Service Provider" - Arkansas

432 times
Rate (4.6 / 5) 26 votes
Arkansas Secretary of State
1401 W. Capitol, Suite 250, Little Rock, AR 72201
John Thurston
501-682-3409 • www.sos.arkansas.gov
TERMINATION OF CERTIFICATE OF FRANCHISE AUTHORITY FOR
VIDEO SERVICE PROVIDER
1. Video Service Provider:
2. Date Certificate of Franchise Authority Was Issued by Secretary of State:
3. Date of Termination:
4. Please identify below, the political subdivisions and/or parts of political subdivisions to whom the Video Service provider has given
written notice of termination.
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.)
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.)
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:
Title
Signature
Date
Printed Name
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
TERMINATION OF CERTIFICATE OF FRANCHISE AUTHORITY FOR
VIDEO SERVICE PROVIDER
1. Video Service Provider:
2. Date Certificate of Franchise Authority Was Issued by Secretary of State:
3. Date of Termination:
4. Please identify below, the political subdivisions and/or parts of political subdivisions to whom the Video Service provider has given
written notice of termination.
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.)
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.)
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:
Title
Signature
Date
Printed Name
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