CHAPTER 14A APPENDIX

APPLICATION FOR SPECIAL CERTIFICATE TO OFFER SHARED AND/OR RESOLD TELEPHONE SERVICE PURSUANT TO G.S. 62‑110(e) CHAPTER 14A SPECIAL CERTIFICATE NO. ____

Note:  To apply for special certification, Applicant must submit a filing fee of $25.00 and the typed

original and 8 copies of this document to the Commission at the following address:

Chief Clerk

North Carolina Utilities Commission

4325 Mail Service Center

Raleigh, NC 27699-4325

DATE OF APPLICATION ______

APPLICANT

_________________________________________________________________________________

(NAME)

_________________________________________________________________________________

(STREET)

_________________________________________________________________________________

(CITY, STATE, ZIP)

TELEPHONE (        )________________________

I certify that I have read and agree to abide by the Rules in Chapter 14A of the North Carolina Utilities Commission attached as Appendix A to this application.

ADDRESS AND DESCRIPTION OF PREMISES TO BE SERVED AND SERVICES TO BE OFFERED: (A map may be attached).

REPRESENTATIVE TO WHOM COMPLAINTS SHOULD BE ADDRESSED:

__________________________________________________________

(NAME)

__________________________________________________________

(STREET)

__________________________________________________________

(CITY, STATE, ZIP)

__________________                                                                                                       ___________________________

Date                                                                                                                                       Signature of Applicant

__________________                                                                                                       ___________________________

Telephone                                                                                                                           Title

VERIFICATION

STATE OF _____________ COUNTY OF _____________________

The above-named ____________________________, personally appeared before me this day and, being first duly sworn, says that the facts stated in the foregoing application and any exhibits, documents, and statements thereto attached are true as he verily believes.

WITNESS my hand and notarial seal, this ____ day of ____ 1998.

___________________________

Notary Public

My Commission expires: _______