| Federal Communications Commission |
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OMB Control Number 3060-0700 |
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| Washington, D. C. 20554 |
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| FCC FORM 1275 |
| CERTIFICATION FOR OPEN VIDEO SYSTEMS |
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| A. Company Information |
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| Company Name: |
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| Contact Person: |
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| Mailing Address: |
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| City: |
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State: |
Zip Code: |
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| Phone Number: |
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Fax Number: |
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| B. Attach a statement of ownership, including all affiliated entities |
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| C. Eligibility and Compliance Representations |
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Yes |
No |
N/A |
| 1. If you are a cable operator applying for certification within your cable franchise area, are you |
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| qualified to operate an open video system under 47 C.F.R. § 76.1501? |
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| 2. Do you agree to comply and to remain in compliance with each of the Commission's |
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| regulations in 47 C.F.R. §§ 76.1503, 76.1504, 76.1506(m), 76.1508, 76.1509, and 76.1513? |
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| 3. Do you agree to comply with the Commission's notice and enrollment requirements |
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| for unaffiliated video programming providers? |
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| 4. If applicable, do you agree to file changes to your cost allocation manual at least |
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| 60 days before the commencement of service? |
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| D. System Information |
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| 1. Provide a general description of the anticipated communities or areas to be served upon completion of the system. |
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| 2. Anticipated Digital Capacity: |
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3. Anticipated Analog Capacity: |
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| 4. If Switched Digital, Anticipated Number of Channel Input Ports: |
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| E. Verification Statement |
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| WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT |
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| (U.S. CODE TITLE 18, SECTION 1001), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503) |
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| To the best of my knowledge and belief, the representations made herein are accurate according to the most recent information available. |
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| Name: |
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Signature: |
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| Title: |
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Date: |
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