POLE ATTACHMENT LICENSE APPLICATION CHECKLIST
Please check each item to ensure they have been fully completed. Please enclose all required Application documentation and mail to:
FairPoint Communications - NNE
License Administration Group
5 Davis Farm Rd
Portland, ME 04103
Fax Number: 207-797-1421
APPLICATION CHECKLIST
Type of Business – Please Choose One
Authorized Telecom Provider
CATV – Cable Television
Independent Telephone Company
Other
Enclosed -Completed License Application Forms - Appendix IV Forms as
applicable.
Check for Pre-construction Survey
POLE ATTACHMENT
AGREEMENT CHECKLIST
Please check each item to ensure they have been fully completed. Please enclose all required Agreement documentation and mail to:
ME, NH, VT
Glen Fournier
AgreementSpecialist
FairPoint Communications - NNE
5 Davis Farm Rd
Portland, ME 04103
Tel: (207)878-0848
Fax: (207)797-1421
E-mail:
*Note – page 2 and 3 to be completed for New Agreements only!
AGREEMENT CHECKLIST
Type of Business – Please Choose One
Authorized Telecom Provider
CATV – Cable Television
Independent Telephone Company
Other
Enclosed-Agreement Check - $425 new agreement.
Enclosed-updated Certificate of Insurance – signed by an authorized
representative of your insurance company. If not currently on file.
Enclosed –Appendix II Customer Profile Sheet – Form 3 complete with all
requested name and address information.
Name, Address and Telephone number of person negotiating this
Agreement: (This person will receive the fully executed Agreement)
Name:Address:
Telephone Number: Fax Number:
AGREEMENT CHECKLIST
Corporate Title: (Name in which Agreement will be issued must
match exactly). Please note that Insurance must be issued in the exact same name as the Agreement. All applications must be issued in the exact same name as the Agreement.
Corporate Title:Legal Address:
State of Incorporation:
Municipality of Principal Office:
Enclosed-Letter of Agency – Required if you are acting on behalf ofthe cable owner.
Serving Electric Company ______
Municipality and State for which Agreement is being requested.
Municipality: ______
State: ______
Pole Attachment Agreement/Application Checklist Page 1 of 3
CHARLOTTE #16354 v1