APPLICATION FOR RENEWAL OF FRANCHISE
OR CERTIFICATE OF CONFIRMATION
1. The exact legal name of applicant
is:
2. Applicant does business
under the following trade name or names:
3. Applicant's mailing address is:
4. Applicant's telephone number(s) is
(are):
5.
(a) This application is for a renewal of
operating rights in the(city, town or village) of________.
(b) Applicant serves the following additional
municipalities from the same headend or from a different headend but in the
same or an adjacent county:
6. The number of subscribers in each of the
municipalities noted above is:
Primary residential connections:
Secondary residential connections:
Residential pay-cable subscriptions:
Commercial connections:
Other:
7.
The following signals are regularly carried by the applicant's cable system
(where signals are received other than by direct off-air pickup, please so
indicate):
8. Applicant does
________ does not ________ provide channel capacity and/or production facilites
for local origination. If answer is affirmative, specify below the number of
hours of locally originated programming carried by the system during the past
twelve months and briefly describe the nature of the programming:
9. The current monthly rates for service in
the municipality specified in Question 5(a) are:
Primary connections:
Secondary connections:
Pay-cable subscriptions:
Commercial connections:
Other:
10.
How many miles of new cable television plant were placed in operation by
applicant during the past twelve months in the municipality specified in
Question 5(a)?
In the municipalities specified in Question 5(b)?
11. State and describe below any
significant achievements and/or improvements that took place with respect to
system operation during the past twelve months:
12. Indicate whether applicant has previously
filed with the State
Commission on Cable Television its:
(a) Current Statement of Assessment pursuant
to Section 817
of the Executive Law? Yes ________ No ________
(b) Current Annual Financial
Report? Yes ________ No ________
If answer to any of above is negative, explain:
13. Has any event or
change occurred during the past twelve months which has had, or could have, a
significant impact upon applicant's ability to provide cable television
service?
If so, describe below:
Signature
Title
________
Date
Please attach a copy of applicant's current annual performance
test results per 9 NYCRR ยง596.5.
STATE OF NEW YORK)
) SS.:
COUNTY OF ALBANY)
VERIFICATION
[Name], being first duly sworn, deposes and says:
1. I am [Title] of [Name of Company] and I am
familiar with the business operations of said company.
2. This application was prepared by me or
under my direct supervision.
3. All
of the statements and information contained herein are true and accurate to the
best of my knowledge and belief.
[Signature]
Sworn to before me this day of________,
19________.
______________
[Notary Public]
