Telecommunications Carrier Registration

Telecommunications Carrier Registration

Company Information

Company Name:
dba Name(s):
Address:
City:
State:
Zip Code:
Country:
Telephone Number:
Toll-Free Customer
Service Tele No.:
Primary Fax:

Regulatory Contact Person Information

Name:
Address:
City:
State:
ZipCode:
Country:
Telephone Number:
Primary Fax:
E-Mail:

Operations

Enter a description of your company's existing telecommunications operations and general service areas in any other jurisdictions.

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What towns or geographic areas in Montana will you serve?

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What markets In Montana will you serve?

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Enter a description of facilities and equipment that will be used to provide service in Montana.

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Parent Company Information (if applicable)

List below the names,addresses and telephone numbers of any parent companies (if applicable).

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Principals (if applicable)

List below the names, principal addresses and telephone numbers of any subsidiary and/or affiliate companies (if applicable).

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Services You Provide OR Intend to Provide in Montana

Local Exchange Services:

☐ Not Offered

☐ Facilities-based

☐ Resale

☐ Combination (facilities-based & resale)

Long Distance Services:

☐ Not Offered

☐ Facilities-based

☐ Resale

☐ Combination (facilities-based & resale)

Commercial Mobile Radio Service:

☐ Yes

☐ No

Other:

☐ Yes

☐ No

If yes, please specify other services:

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Miscellaneous

Start of service date: Click here to enter text.

Does your company intend to draw from the Universal Service Fund or other explicit support funds?

☐ Yes

☐ No

Does your company intend to seek PSC designation as an eligible telecommunications carrier?

☐ Yes

☐ No

Has any Court or State or Federal regulatory agency taken formal action against your company that resulted in any type of penalty or sanction within the last 5 years?

☐ Yes

☐ No

If yes, please describe the action(s) taken and the penalties/sanctions imposed:

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Company Incorporation Information

Is your company incorporated?

☐ Yes

☐ No

If no, please provide the following information:

Form of ownership: Click here to enter text.

Date of business entity creation (mm/dd/yyyy): Click here to enter text.

Principal owners’ and Managers’ names and addresses:

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Agent for Service of Process in Montana, name and address:

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Return the completed form to the Montana Public Service Commission at:

E-Mail:

Form Updated 5/29/2018