Area A: Company Identification

A.1

Legal name of Entity

A.2

Name under which the Telecommunications Service Provider (TSP) carries on business

A.3

List of Related TSPs (provide separate list if required) (Note 1)

Area B: Contact Information

B.1

Person who completed this form

B.2

Title of Position

B.3

Telephone number

B.4

Fax number

B.5

Email address

Area C: Reporting Year Information – Attach Copy of Relevant Financial Statements

C.1

Reporting year (Note 2)

C.2

Fiscal year end