ࡱ> \^[#` 5bjbj\.\. .F>D>D-+++8+ +48,,,,,,,, 8 8 8 8 8 8 8$z9h;X18e.,,e.e.18,,F8///e.^,, 8/e. 8///,, PPv+.R/ 8\808/:</:</:</,,h/ -T^-,,,1818/ ,,,8e.e.e.e. EXHIBIT A CITY OF HAMPTON APPLICATION FORM This Application is for a usage agreement in the City of Hampton for the construction, operation and/or maintenance of communications services or facilities in the Citys rights-of-way. This application requires payment of a non-refundable application fee of . For purposes of this Application Form, the term Communications Service means the transmission of writing, signs, signals, pictures, sounds or other forms of intelligence through wire, wireless or other means, including, but not limited to, any telecommunications service, cable service, enhanced service, information service, or Internet service, as such terms are now, or may in the future be, defined under federal law, and including all instrumentalities, facilities, apparatus, and services (among other things, the receipt, forwarding, and delivery of communications) incidental to such transmission. PART A: GENERAL INFORMATION 1. Name of Applicant, Including All Affiliates of the Applicant: Applicant: Date: Affiliates: 2. Address of Applicant: 3. Name and Telephone Number of Contact Person for Applicant: 4. Is this an Application for (check all that apply and explain): a. An initial license to construct, operate and/or maintain ducts, conduits or other facilities in the Citys rights-of-way . b. An initial license to utilize the Citys rights-of-way to provide any Communications Service . c. An expansion, change, or modification of an existing system or amendment of a Franchise to change or expand services or facilities . d. Other, describe: PART B: DESCRIPTION OF PROPOSED CONSTRUCTION PLANS, THE SYSTEM AND SERVICES 1. Describe in Detail: a. The geographic area within the City of Hampton in which the Applicant proposes to construct its facilities and/or offer Communications Service and a schedule for buildout to entire area. b. Types of facilities to be installed, constructed or utilized (e.g., reinforced conduit, duct banks, fiber, co-axial cable, copper twisted pair) and the precise location within the public rights-of-way or other locations where such facilities will be placed. c. The location of all facilities, including the use of existing overhead and underground public utility, conduit, telecommunications cable, water, sewer drainage and other facilities, in the public right-of-way along the proposed route, or other locations. (1) If the facilities are to be installed overhead, identify the space available for locating telecommunications facilities on existing utility poles along the proposed route. (2) If the facilities are to be installed underground in existing ducts or conduits, identify: (i) The available capacity in such ducts or conduits before installation of Applicants facilities. (ii) The capacity that will remain after the Applicants facilities are installed. (iii) The number and location of additional manholes or handholes required. (3) If Applicant is proposing to install new ducts or conduits underground in the public rights-of-way, identify: (i) The proposed location(s). (ii) The excess capacity that will exist after installation. (iii) The number, size and location of vaults, manholes and handholes required. (iv) Other equipment and facilities to be installed. d. The specific trees, structures, improvements, facilities, and obstructions, if any, that Applicant proposes to temporarily or permanently remove or relocate. e. Provide a scaled blueprint map of the proposed service area visually indicating the same information. 2. Assuming that the Applicant obtains permission to use the public rights-of- way for the term proposed by the Applicant, describe the types of facilities and/or services that the Applicant plans to provide during the relevant term. This information is necessary for the City to assess the proper fee under law. a. Does the Applicant plan to offer private switched telephone services to customers? b. Does the Applicant plan to offer local switched telephone services to Hampton residents either through its own facilities or as a resale carrier? c. Does the Applicant plan to offer long-distance services either through its own facilities or as a resale carrier? d. Does the Applicant plan to offer any type of video programming service to its customers, including cable television, open video system service, or video dialtone service? e. Does the Applicant intend to lease or sell dark fiber on its system to other entities? f. Does the Applicant intend to lease or sell transmission capacity on its system to other entities? g. Does Applicant intend to lease or sell space in ducts or conduits for use by other entities? h. Does Applicant intend to lease or sell Internet access services, security services, energy-related services or any other Communications Services not previously listed in this section? 3. If any of the questions in paragraph 2 of this Application were answered yes, please describe in detail to whom, how, and when such services or facilities will be offered. Please note separate facilities owned by another but utilizing Applicants facilities, including conduits, are subject to the Application requirements and fees imposed by the City. 4. Has the Applicant reviewed the construction standards set forth in the Construction and Administration Ordinance? Provide a schedule and completion dates for development and construction of the Applicants proposed facilities, Telecommunications System or Open Video System. 5. Please describe the Applicants proposed maintenance plan. a. If leasing access to ducts or conduits by third-party Communications Service providers, please explain the installation and maintenance procedures for such third-party communications facilities. 6. Has the Applicant reviewed the conditions and requirements regarding licensing and permits set forth in the Construction and Administration Ordinance and Telecommunications Ordinance? 7. If the Applicant proposes to provide any Communications Service, has the Applicant obtained all required federal, state and local permits, licenses, certificates and Franchises and met all other legal requirements? If yes, please attach all relevant documentation. 8. If the Applicant has not yet complied with all relevant legal requirements, provide detailed documentation of the steps that the Applicant has taken, or intends to take, toward that end. 9. Will the Applicant have a local office in the City? If so, how many employees will it office? In what capacity will the employees serve? Will such employees perform construction and maintenance on the system? Will such employees serve as a local contact for the City regarding the Construction Ordinance and the applicants use agreement? 10 If applicant intends to provide open video service, provide a description of services that Applicant will offer or make available to the City and other public, educational, and governmental institutions. 11. Provide a detailed estimate of construction costs for the Initial System with respect to the use of the Citys rights-of-way, including excavation and right- of-way restoral, or if this Application relates to a request to expand the type, scope, or geographical location of services, a detailed estimate of the right- of-way construction costs of such expansion. This information will be subject to independent verification by the City. PART C: APPLICANT 1. Please provide the names and titles of each general or limited partner, officer, or director if the Applicant. Also provide the names of any shareholder of the Applicant owning more than 5% of the Applicants outstanding common stock (if the Applicant is a corporation). 2. Please list any subsidiaries, or other entities in which the Applicant owns a controlling equity interest. 3. Please provide an organizational chart of the Applicants operations. 4. If intending to provide any Communications Service, describe how you will operate locally to serve the City. Specifically address where the Applicant intends to open a local office in the City, what other administrative facilities will be located in City, how many persons will be employed by the Applicant in City. 5. Please provide the City with contact names, addresses, and phone numbers of three municipalities where the Applicant has been granted permission to use the public rights-of-way to provide any Communications Service. 6. Has the Applicant obtained the right to provide a Communications Service in any other municipality and transferred such right to another entity within five (5) years of obtaining it? PART D: LEGAL BACKGROUND OF APPLICANT 1. Has the Applicant ever been engaged in any litigation with a municipality with respect to use of right-of-way? If so, please describe the nature of the dispute, the municipalities involved, the amount of damages, if any, paid by either party and whether the dispute had been finally resolved. 2. The Telecommunications Act of 1996 (Act) modified the regulatory authority of the city over telecommunications providers and also imposed new requirements on telecommunications providers. Please discuss the Applicants interpretation of how the Act affected the Citys powers to regulate your business in the City. 3. Is the Applicant currently involved in any disputes before any federal, state, or local regulatory agency that would impact the ability of the entity to legally construct, maintain or provide facilities or services in the City? If so, please describe. 4. Have you reviewed the Citys Construction and Administration Ordinance, Telecommunications Ordinance, and Rights-of-Way Use Agreement? Please discuss any objections the Applicant has to any provision, explaining the grounds for those objections. PART E: FINANCIAL BACKGROUND OF APPLICANT 1. Please provide the City with a copy of the Applicants audited financial statements for each of the past three (3) fiscal years, including an income statement, balance sheet, statement of cash flows, and statement of owners equity. This information is required to determine whether the applicant can insure the costs of all right-of-way related costs, and liabilities. 2. What will the cost be for the right of way construction of the proposed facilities or services? 3. How will the Applicant finance the cost of the right-of-way construction for the proposed facilities or services? Please provide proof of the availability of such financing. 4. Please submit a proposal for a security fund of some kind adequate to protect the Citys interest in ensuring that all construction and related right of way costs for the proposed facilities or services are covered. 5. Has the Applicant ever been placed in a receivership, declared bankruptcy, been declared insolvent, or had property foreclosed upon by a creditor? If so, please explain in detail the circumstances behind each instance. I certify that I am authorized to execute this Agreement on behalf of the Applicant. I further understand that if there are material omissions of information requested by this Application or deliberately false answers given to questions on this Application, the City may revoke any Franchise, permit, or license it has granted in reliance on the answers provided by Applicant to this Application. Further, such actions shall be punished as provided pursuant to the City Code. 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