Communication Service Provider Registration
Applicant Name
*
First Name
Last Name
Applicant's Certificate of Authorization or License No.
*
Please Provide a Copy of your License
*
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Type of authorization or license
*
Please Select
Florida Public Service Commission
Federal Communications Commission
Other Federal or State Authority
Is the applicant a corporation?
*
Please Select
Yes
No
Proof of Authority
*
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For an applicant that does not provide a Florida Public Service Commission certificate of authorization number, if the applicant is a corporation, the applicant must provide sufficient proof of authority to engage in providing communications services in the State of Florida, including, without limitation, the number of the certificate from or filing with the Florida Department of State.
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Primary Contact Person
*
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Evidence of Insurance coverage
*
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