INSTRUCTIONS FOR COMPLETING TELECOMMUNICATIONS PROVIDER REGISTRATION FORM
Please carefully read all sections of these instructions. Failure
to correctly complete the form and produce necessary accompanying documents
will delay the processing of your application for a Certificate of Public
The Public Service Board requires an original and three copies of this
application and all documentation. If any of this documentation is not
filed with the Public Service Board, the application will be considered
deficient and processing of it will be delayed. The application is not
complete unless it includes the entire Registration Form, Sections A, B
and C, and the final attestation.
Item 1. Insert the applicant's name as registered and certified
by the Vermont Secretary of State. The Secretary of State's website
The Secretary of State's mailing address is 109 State Street, Montpelier,
Vermont 05609-1104, the physical address is 81 River Street, Montpelier,
Vermont 05602, the phone number is 802-828-2386, and the fax number is
Item 2. Please include any and all names under which your
company currently does business or proposes to do business. If your
application is approved, you will be required to register any additional
trade name that you wish to use in Vermont in the future with the Secretary
of State and provide a copy to the Public Service Board (PSB).
Item 3. Please check off either yes or no.
Item 4. Insert the applicant's mailing address and phone
number. If corporate address is different, please note this on a
separate attachment, labeled as "Attachment A4." The address and phone
number placed here should be the address the PSB and Department of Public
Service (DPS or Department) will send their communications and annual report
Item 5. Please provide the name, address, and telephone
number of an individual who will be familiar with this application and
whom staff members from the PSB and DPS can call with questions about the
Item 6. Certified telecommunications companies are required
to file an annual report. Please provide the name, address, and telephone
number of the person to whom the DPS would be sending the paperwork necessary
to file the annual report, or indicate that it is the same person listed
in item 5.
Item 7. The registered agent in Vermont is required for
the Secretary of State Certificate of Authority Application Form.
This is the agent the applicant has listed for service of process.
Item 8. The Vermont registered agent's address and telephone
number as found on the Certificate of Authority Application Form as filed
with the Vermont Secretary of State.
Item 9. The applicant's current directors and officers
should be listed here along with their current business address. This information
is also found on the Vermont Secretary of State Certificate of Authority
Application Form. If additional space is needed, please attach a
separate sheet identifying it as "Attachment A8."
Item 10. Although a proposed tariff is not required at
this time, a brief summary of the applicant's services and operations should
be listed here.
Item 11. Identify any other carriers that the applicant
proposes to use to provide service.
Item 12. Make sure to list all states where the applicant
has provided service in the past, even if it is no longer doing so.
Item 13. If the applicant proposes to limit CLEC service
to certain counties, note this.
Item 14. If the applicant has never declared bankruptcy,
the answer to this part would be no. However, if the applicant has
declared bankruptcy, the answer would be yes, and the applicant must complete
Part 1 of Section B.
Item 15. If the applicant has never been the subject of
an investigation by a state or federal authority (other than an investigation
into an application to provide service that was approved), the answer to
this part would be no. If yes, the applicant must complete Part 2
of Section B.
Item 16. If the applicant has never been subject to fines,
penalties or sanctions (monetary or otherwise) by a state or federal authority,
the answer to this part would be no. If yes, the applicant must complete
Part 3 of Section B.
Item 1. Include the requested descriptions and documents
as "Attachment B1."
Item 2. Make sure to describe each and every investigation
for which this item requests a description. Include the requested descriptions
and documents as "Attachment B2."
Item 3. Make sure to include the specific dollar amounts
of any monetary penalties and a detailed description of any other penalties
or sanctions. Include the requested descriptions and documents as
Item 1. Please include a copy of the applicant's Certificate
of Authority from the Vermont Secretary of State (See Section 1, item 1)
and if the applicant intends to provide service by use of a tradename (i.e.
d/b/a), a tradename Certificate from the Vermont Secretary of State is
Item 2. Please include an organizational chart depicting
the applicant's corporate structure including its parent company and all
affiliates and subsidiaries. If more space is required, please attach
a separate page as "Attachment C2."
Item 3. Please include a listing of those shareholders
that have a 5% or more investment in the applicant. If more space
is required please attach a separate page as "Attachment C3."
Item 4. Please provide a Disaster Recovery Plan.
Such a plan must be filed with the Department every three years.
An initial Plan is required for facilities-based carriers with this application.
The italicized section above the signature lines is a legally binding statement. The Vermont statutes and Board rules and the most important Board orders regarding telecommunications carriers can be found in the application package. Please read and consider them and this statement carefully before signing. This statement must be signed by an officer or a duly authorized agent of the company and notarized or the application will not be considered complete.