4. CERTIFICATES OF AUTHORITY TO BE TRANSFERRED:
a. List each certificate of authority previously granted by the Oregon PUC to Transferor, under its legal name, an
assumed business name, or any other name. Include all certificates whether or not canceled. For each certificate
provide the name of entity, docket number, and order number.
Name of Entity Docket Number Order Number
Do you request that ALL authority to provide telecommunications service be transferred?
c. If response to 4.b. is No, describe what authority is to be transferred and what authority is to be retained
by the Transferor.
The transferring entity (Transferor) will no longer be authorized to provide the telecommunications
services that are transferred.
additional sheets if necessary to fully answer any item.
As a condition of a certificate of authority, certificate holder must comply with all applicable Commission rules and state
well as conditions listed in the certificate. The surviving entity (Transferee) is responsible for the annual PUC fee
and all other fees incurred by the transferring entity (Transferor) as of the date the Commission approves the transfer.
For your convenience, following is a summary of some conditions from OAR 860 Divisions 32 and 33. Additional
conditions may be specified in the certificate.
Certificate holder must:
• Provide only the telecommunications service authorized in the certificate.
• Respond in a timely manner to Commission inquiries
• Notify the Commission of changes to the certificate holder’s name, address, email, or telephone number.
• Maintain its books and records according to the applicable rules of the Commission, and keep its books and records
open to inspection by the Commission to the extent necessary to verify information required of the certificate holder.
• Meet service standards set forth in applicable Commission rules, including OAR 860-032-0012.
• Submit required reports in a timely manner, and timely pay all Commission taxes, fees, assessments, access
charges, and subsidies pursuant to Oregon law or Commission rules, orders, tariffs, or price lists.
• Pay an annual fee to the Commission pursuant to the Commission’s rules. This fee will be based on the certificate
holder’s annual gross retail intrastate revenues and will be no less than $100 per calendar year. Certificate holder
must collect the fee by charging an equitable amount to each retail customer and describe the amount of the
apportioned charge on each retail customer’s bill, pursuant to the Commission’s rules.
• Pay a quarterly amount to the Oregon Universal Service Fund based on a Commission-approved surcharge
percentage assessed on all retail telecommunications services sold in Oregon pursuant to ORS 759.425(4).
• Ensure that the Residential Service Protection Fund surcharge is remitted monthly to the Commission. This
surcharge is assessed against each paying retail subscriber at a rate that is set annually by the Commission.
SECTION 3 – Nature of Transaction between Transferee and Transferor (describe in detail)
SECTION 4 – Conditions of a Certificate of Authority
FM 905 Rev. 7/2018