Form FMC-83 Service Contract Registration

ORGANIZATION NO.

PLEASE TYPE OR PRINT

SERVICE CONTRACT REGISTRATION
(SEE ATTACHED INSTRUCTIONS)

1. Organization Number
2. Registrant Type
(Check all that applies)

[ ] VOCC

[ ] Tariff Publisher/Agent/Other

[ ] Agreement

[ ] Conference/Joint Service

3. Registrant
Full Legal Name of firm (or individual, if not a firm)
(Doing Business As)

4. This Registration is:

[ ] Initial

[ ] Amendment (Specify change)

[ ] Dial-up

[ ] Internet-based

5. Address of
Home Office

(
(Number and Street)

)

Telephone

(Please record any changes)

(
(Number and Street)

(City/State/Country)

6. Billing
Address If
Different

(Federal TIN Number)

)
Fax

E-Mail (optional)

(

)

(Number and Street)

Telephone

(Number and Street)

Fax

(City/State/Country)

E-Mail (optional)

(

)

7. Permissions Requested and Person granted these permissions : For the Internet-based system, please list individual(s) who will
need logons. If the individual is a publisher, a letter of authority must be submitted.

Full Legal Name

If this is transfer of logon, please list for each the
Existing Log-on____________________

File Service Contracts


Signature of Authorized Official

Print or Type name of Authorized Official

date

FMC USE ONLY
Logon__________________Initial Password__________________ID___________________Directory__________________
DateAsg_____/_____/_____AsgBy___________________________
Form FMC-83 (3/99)

INSTRUCTIONS FOR FORM FMC-83

INSTRUCTIONS
Line 1. Organization Number: Complete if known. (Regulated Persons Index or
“RPI” number.)
Line 2. Registrant Type: Indicate the type of organization. Please check all that
applies.
Line 3. Registrant: This must be the full name of the firm or individual registering
for the FMC’s Service Contract Filing System and any trade names. The registrant
name should match the corporate charter or business license, conference
membership, etc. It should be noted that the registrant name cannot be changed by
the registrant after the registration without submission of an amended registration
form.
Line 4. Registration: Indicate whether this is the initial (first time) registration or an
amendment to an existing Service Contract Registration.
Line 5. Address of Home office: The complete street address should be shown in
addition to the post office box. Also, provide the registrant’s Federal Taxpayer
Identification Number (“TIN” Number).
Line 6. Billing Address if Different: This should be completed if the billing address
differs from the home office address. Show the firm name (if different from the
registrant), street address and post office box (if applicable).
Line 7. Permissions Requested and Person Granted These Permissions: Delegation
of the authority to file should be noted here. The person listed in line 7 is authorized
only to submit filings.