Sample Section 214 Application

Any party seeking to provide common carrier communications services between the United States and a foreign point ("U.S.-international services") must request authorization from the Federal Communications Commission pursuant to Section 214 of the Communications Act of 1934, as amended. 47 U.S.C. § 214. The Commission’s rules applicable to Section 214 applications are found in Title 47 of the Code of Federal Regulations in rule 63.18. 47 C.F.R. § 63.18.

Applicants must file Section 214 applications electronically through the International Bureau’s Filing System (IBFS) on the Commission’s website. Applicants have the option of paying online by credit card. For questions or assistance about payment options, applicants may view the Payment Instructions located on the IBFS website. Instructions for filing an electronic Section 214 are located on the International Bureau’s IBFS website under Filing Instructions. Applicants with questions about filing electronically must call (202) 418-2222 or visit the IBFS website.

The Commission has adopted procedures to streamline applications for international Section 214 authorization under Section 63.18 of the Commission's Rules, 47 C.F.R. § 63.18. See Streamlining the International Section 214 Authorization Process and Tariff Requirements, IB Docket No. 95-118, Report and Order, FCC-96-79 (1996); 1998 Biennial Regulatory Review—Review of International Common Carrier Regulations, IB Docket No. 98-118, Report and Order, FCC 99-51 (1999). Each week, the International Bureau’s Policy Division releases public notices announcing applications for international Section 214 authority and cable landing licenses that are accepted for filing and applications. The Division issues public notices regarding applications accepted for streamlined processing, non-streamlined processing, and applications that have been granted pursuant to either processing procedures. The public notices are available on the IBFS website under Public Notice Reports.

Applicants for transfers of control or assignments of international Section 214 authority may file consolidated applications and petitions for declaratory ruling for approval of indirect foreign ownership in excess of 25% pursuant to Section 310(b)(4) of the Communications Act; however, applicants must clearly designate the contents of their applications and provide the necessary information and demonstrations for the Commission to consider each separate request. Review of Section 310(b)(4) requests is based upon the standards set forth in the Foreign Participation Order, 12 FCC Rcd 23,891 (1997). We also note that such combined international Section 214 applications and petitions for declaratory rulings under Section 310(b)(4) are not eligible for streamlining procedures. We request that Applicants refer to recent Commission orders addressing approval of Section 310(b)(4) requests regarding the necessary information and public interest showings such petitions must demonstrate. See, e.g., Application of VoiceStream Wireless Corporation, Powertel, Inc., Transferors, and Deutsche Telekom AG, Transferee, for Consent to Transfer Control of Licenses and Authorizations Pursuant to Sections 214 and 310(d) of the Communications Act and for Declaratory Ruling Pursuant to Section 310 of the Communications Act, Memorandum Opinion and Order, 16 FCC Rcd 9779 (2001).

The following information provides general guidelines for filing a Section 214 application. Applicants also should refer to the Commission’s rules regarding U.S.-international carriers, available on the International Bureau homepage under Rules for International Carriers and the Commission’s 1997 market access policies set forth in the Rules and Policies on Foreign Participation in the U.S. Telecommunications Market, IB Docket Nos. 97-142 and 95-22, Report and Order and Order on Reconsideration, 12 FCC Rcd 23,891 (1997) (Foreign Participation Order), Order on Reconsideration, 15 FCC Rcd 18,158 (2000) (Foreign Participation Recon Order), as well as the Commission’s policies regarding accounting rate conditions on Section 214 authorizations and the provision of International Simple Resale (ISR). See In the Matter of International Settlement Rates, Report and Order, 12 FCC Rcd 19,806 (1997) (Benchmarks Order); Report and Order on Reconsideration and Order Lifting Stay, 14 FCC Rcd 9,256 (1999) (Benchmarks Reconsideration Order), aff’d sub nom. Cable and Wireless P.L.C. v. FCC, 166 F.3d 1224 (D.C. Cir. 1999). Information for electronic filing may be found in the Section 214 Filing Instructions contained on the IBFS website for IBFS Filing Instructions.

Should applicants require additional information about Commission requirements, please contact the International Bureau’s Policy Division at (202) 418-1460. The Commission staff is available to provide general guidance to applicants about how the Commission’s rules and policies may apply to the specific factual circumstances of the applicant. The staff will not, however, give official interpretations of the rules and policies, nor will it engage in discussions based upon hypothetical scenarios. Priority for the staff is to work on applications pending before the Commission. Applicants seeking an official interpretation from the Commission may file a petition for declaratory ruling pursuant to Section 1.2 of the Commission’s rules. 47 C.F.R. § 1.2.

In addition, members of the public with suggestions on how to improve these guidelines may provide their comments to the International Bureau’s Policy Division.

An applicant seeking Section 214 authorization to construct a new line, or to acquire or operate any line, or engage in transmission for the provision of common carrier communications services between the U.S. and a foreign point must request such authority by formal application. 47 C.F.R. § 63.18. Applicants may request authority to provide U.S.-international services on a facilities-basis and/or resale-basis, and may request such authority to apply globally or to specific foreign points. In addition, Applicants seeking to provide International Simple Resale (ISR) on a facilities or resale-basis must apply for the appropriate Section 214 authority to provide such services on ISR-approved routes. The International Bureau maintains a current list of ISR-approved routes on its website.

An international Section 214 authorization permits a carrier to provide U.S.-international services on a common carrier basis subject to the provisions of the "exclusion list" contained in such authorizations. The exclusion list contains a list of U.S.-international routes to which Section 214 authority does not apply and it also lists methods by which Section 214 holders may not provide services. Currently, the exclusion list associated with international Section 214 authorizations prohibits authorized carriers from serving Cuba without complying with the separate filing requirements of the Commission’s Public Notice Report No. I-6831 (1993), and using non-U.S.-licensed satellite systems that are not on the "Permitted Space Station List," maintained at www.fcc.gov/ib/srd/se/permitted.html.

An applicant must submit an application fee with an application for Section 214 authorization. The current filing fee can be found in the FCC’s fee filing guide. 47 C.F.R. § 1.1107(2)(c).

In addition, applicants must have a ten-digit FCC Registration Number (FRN). FRNs permit the Commission to track payment of regulatory fees. FRNs are assigned by the Commission Registration System (CORES). The FRN is a unique identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC CORES webpage (www.fcc.gov) or by requesting FCC Form 160 through the FCC forms webpage (www.fcc.gov/formpage.html). All parties on an application, e.g., transferees and transferors, parent and subsidiary corporations, must each have a FRN.

A. Application

Section 63.18 specifies the information that must be included in an application for Section 214 authorization. 47 C.F.R. § 63.18. Chapter III below explains Section 63.18 requirements in detail.

B. Application Fee

An applicant must submit an application fee with an application for Section 214 authorization. The current filing fee can be found in the FCC’s International Fee Filing Guide. 47 C.F.R. § 1.1107(2)(c). Applicants have 3 basic options for submitting payment to the FCC: (1) pay by check; (2) pay by credit card; (3) pay by wire transfer or electronic funds transfer. The IBFS website contains Payment Instructions that will provide assistance to properly making a payment. If no fee payment is received within 14 calendar days from the date of filing an application, your application may be dismissed.

Applicants must attach the fee form cover sheet, FCC Form 159, to their applications and submit them to the appropriate address at Mellon Bank in Pittsburgh, PA. (See the International Fee Filing Guide for the appropriate address.) Unless applications involve supplementation of existing international facilities and the issuance of a certificate is not required, applicants must file an original and 5 copies of the application. Applicants should consult Section 63.20 of the Commission’s rules regarding the appropriate number of copies that must be filed. 47 C.F.R. § 63.20.

Applicants may transfer multiple Section 214 authorizations that they hold, e.g., separate facilities-based and resale-based Sections 214 authorizations, on a single application and under a single fee. However, a separate application must be filed and a separate fee must be paid for each licensee of record. 47 C.F.R. § 1.1107.

Any requests for return or refund of fees must be made pursuant to Section 1.1113 of the Commission’s rules and Section 0.231 of the Commission’s rules as appropriate. 47 C.F.R. §§ 0.231, 1.1113.

C. Streamlined Processing Procedures (47 C.F.R. §§ 63.12 (a)-(b))

An application eligible for streamlined processing submitted under Section 63.18 will be granted fourteen days after issuance of the public notice stating that the application has been accepted. 47 C.F.R. § 63.12 (a). Authorization for the services proposed under the application takes place on the fifteenth day after the issuance of the public notice. 47 C.F.R. § 63.12 (b).

1. Eligibility for Streamlined Processing (47 C.F.R. § 63.12 (c))

Applicants for global facilities-based or resale authority are eligible for streamlined processing unless otherwise prohibited from doing so by Section 63.12(c) of the Commission’s rules. 47 C.F.R. § 63.12 (c). The Commission reserves the right to remove applications from streamlining. Insufficiency of an application may result in denial or removal from streamlining procedures. An application does not qualify for streamlined processing if:

1. The applicant is affiliated with a foreign carrier in a destination market it seeks authority to serve, unless the applicant clearly demonstrates in its application at least one of the following:

2. The applicant has an affiliation with a dominant U.S. carrier whose international switched or private line services the applicant seeks authority to resell (either directly or indirectly through the resale of another reseller’s services), unless the applicant agrees to be classified as a dominant carrier to the affiliated destination country under Section 63.10 (without prejudice to its right to petition for reclassification at a later date); or

3. The applicant seeks authority to provide switched basic services over private lines to a country for which the Commission has not previously authorized the provision of switched services over private lines; or

4. The Commission has informed the applicant in writing, within fourteen days after the date of public notice listing the application as accepted for filing, that the application is not eligible for streamlined processing.

Reference to the dominant status of U.S.-international carriers, unless otherwise noted, means dominant classification set forth in 47 C.F.R. § 63.10. The regulatory safeguards imposed on U.S. carriers that are regulated as dominant on particular routes because of a U.S. carrier’s affiliation with a foreign carrier with market power differ from the regulatory safeguards that the Commission has imposed on U.S. carriers that are dominant for reasons other than a foreign carrier affiliation, e.g., tariff requirements.

Applicants must provide information required by Section 63.18 of the Commission’s rules. 47 C.F.R. § 63.18. A sample application is attached the bottom of these guidelines that applicants may follow.

Insufficiency of an application may result in denial or removal from streamlining procedures. Applicants are also under an obligation to maintain the continuing accuracy and completeness of information furnished in a pending application pursuant to Section 1.65 of the Commission’s rules, 47 C.F.R. § 1.65. The Commission may request further information as necessary pursuant to Section 1.17 of the Commission’s rules, 47 C.F.R. § 1.17, and Sections 4(i) and 403 of the Communications Act, 47 U.S.C. §§ 154(i), 403.

The information required to be included in initial Section 214 applications also is required to be included in applications to assign or transfer control of international Section 214 authorizations. See Part III.B.3 below. In most cases, information is required of both the transferee/assignee and transferor/assignor. The information required for pro forma assignments and transfers of control, however, is specified in Section 63.24 of the Commission’s rules. 47 C.F.R. § 63.24. A pro forma assignment or transfer of control involves no change in the ultimate control of the authorization as set forth in Section 63.24(a), e.g., one wholly-owned subsidiary of a corporation transfers a Section 214 authorization to another wholly-owned subsidiary of the same corporation.

Transfer and assignment of domestic Section 214 authorizations are subject to the relevant rules and regulations regarding the treatment of domestic Section 214 authorizations. See Implementation of Further Streamlining Measures for Domestic Section 214 Authorizations, CC Docket No. 01-150, FCC 02-78 (rel. Mar. 21, 2002).

A. Preamble

In this first part of a Section 214 application, the applicant shall briefly describe itself to the Commission, e.g., its full name, line of business, place of operations and incorporation, its ownership, and affiliations. This description must include any telecommunications services already provided by the applicant or its affiliates, any foreign affiliations, the reason for the application, and how the public interest, convenience, and necessity would be served by a grant of the application. An applicant for a transfer of control or assignment must also include a narrative describing the transaction and explaining the potential public interests served by the applied-for transactions. The description must include the timing of the proposed transaction, any legally-mandated deadlines involved in a transaction, descriptions of all parties involved and their businesses, and how the transaction will benefit the public interest. 47 C.F.R. § 63.18(e)(3).

B. Section 63.18 Information

In the second part of a Section 214 application, the applicant shall provide the following information as required by 47 C.F.R. § 63.18.

1. The name, address, and telephone number of each applicant. We note in greater detail below that in the case of transfers of control or assignees, information must be provided regarding both transferees/transferors, assignees/assignors;

2. The Government or State under which the applicant is incorporated or organized;

3. The name, title, post office address, and telephone number of the officer and any other contact person to whom correspondence concerning the application is to be addressed;

4. A statement as to whether the applicant received Section 214 approval from the Commission for any services prior to the present application. If such approval was granted, the applicant shall provide a brief description of its authorized facilities and services.

1. the applicant is a foreign carrier in a destination country;
2. the applicant controls a foreign carrier in a destination country;
3. any entity that owns more than twenty-five percent of the applicant, or that controls the applicant, also controls a foreign carrier in a destination country;
4. two or more foreign carriers (or carriers that control the foreign carriers) own more than twenty-five percent, in the aggregate, of the applicant and are parties to, beneficiaries of, have a contractual relation affecting the provision or marketing of U.S.-international services in the United States.

1. The named destination country is a signatory of the WTO; or
2. The applicant’s foreign affiliate lacks market power in the named country; or
3. The named country provides Effective Competitive Opportunities (ECO) to U.S. carriers to compete in that country’s market for the service that the applicant seeks to provide. See Section 63.18(k)(3) of the Commission’s rules, 47 C.F.R. § 63.18(k)(3), and the Foreign Carrier Entry Order, 11 FCC Rcd 3873 regarding the ECO test.

Most definitions applicable to the provision of U.S.-international services are contained in Section 63.09 of the Commission’s rules. 47 C.F.R. § 63.09. Definitions are also found in Section 3 of the Communications Act. 47 U.S.C. § 153.

1. Facilities-Based Carrier (47 C.F.R. § 63.09(a))

Facilities-based carrier means a carrier that holds an ownership, indefeasible-right-of-user, or leasehold interest in bare capacity in the U.S. end of an international facility, regardless of whether the underlying facility is a common carrier or non-common carrier submarine cable or a satellite system.

2. Control (47 C.F.R. § 63.09(b))

Control includes actual working control in whatever manner exercised and is not limited to majority stock ownership. Control also includes direct or indirect control, such as through intervening subsidiaries.

3. Special Concession (47 C.F.R. § 63.14(b))

A special concession is defined as an exclusive arrangement involving services, facilities, or functions on the foreign end of a U.S.-international route that are necessary for the provision of basic telecommunications services where the arrangement is not offered to similarly situated U.S.-licensed carriers and involves:

(1) Operating agreements for the provision of basic services;

(2) Distribution arrangements or interconnection arrangements, including pricing, technical specifications, functional capabilities, or other quality and operational characteristics, such as provisioning and maintenance times; or

(3) Any information, prior to public disclosure, about a foreign carrier's basic network services that affects either the provision of basic or enhanced services or interconnection to the foreign country's domestic network by U.S. carriers or their U.S. customers.

 

4. Foreign Carrier (47 C.F.R. § 63.09(d))

A foreign carrier is defined as any entity that is authorized within a foreign country to engage in the provision of international telecommunications services offered to the public in that country within the meaning of the International Telecommunication Regulations, see Final Acts of the World Administrative Telegraph and Telephone Conference, Melbourne, 1988 (WATTC-88), Art. 1, which includes entities authorized to engage in the provision of domestic telecommunication services if such carriers have the ability to originate or terminate telecommunications services to or from points outside their country.

5. Affiliation (47 C.F.R. § 63.09(e))

Two entities are affiliated with each other if one of them, or an entity that controls one of them, directly or indirectly owns more than 25 percent of the capital stock, or controls, the other one.

Also, a U.S. carrier is affiliated with two or more foreign carriers if the foreign carriers, or entities that control them, together directly or indirectly own more than 25 percent of the capital stock of, or control, the U.S. carrier and those foreign carriers are parties to, or the beneficiaries of, a contractual relation (e.g., a joint venture or market alliance) affecting the provision or marketing of international basic telecommunications services in the United States.

6. Market Power (47 C.F.R. § 63.09(f))

Market power means sufficient market power to affect competition adversely in the U.S. market. See Foreign Participation Order, 12 FCC Rcd 23,891 (1997).

7. Interlocking Directorates (47 C.F.R. §63.09(g)(1))

Interlocking directorates means persons or entities who perform duties of "officer or director" in an authorized U.S.-international carrier or an applicant for international Section 214 authorization who also performs such duties for any foreign carrier.

8. Officer or Director (47 C.F.R. §63.09(g)(2))

Officer or Director shall include duties, or any of the duties, ordinarily performed by a director, president, vice president, secretary, treasurer, or other officer of a carrier.

9. Effective Competitive Opportunities (47 C.F.R. § 63.18 (k)(3)(i)-(vi))

An effective competitive opportunities demonstration must address the following factors:

                     Sample Application



                         Before the
                              
              Federal Communications Commission
                              
                   Washington, D.C. 20554





In the Matter of                   )
                                   )
XYZ, Inc.                          )
Application Under Section 214      )    File No. TC________
Of the Communication Act of 1934,  )
                                   )
As Amended, for Global Authority   )
                                   )
For the Provision of Resold        )
and Facilities-Based               )
                                   )
International Switched and         )
Private Line Services              )
                                   )
Between the U.S. and Various  )
International Points               )



                         APPLICATION

     XYZ, Inc. ("XYZ" or "Applicant"), by its attorneys and
pursuant to Section 214 of the Communications Act of 1934,
as amended ("the Act"), 47 U.S.C.  214, hereby requests
global authority to (1) operate as a facilities-based
carrier pursuant to the terms and conditions of Section
63.18 (e)(1) of the Commission's Rules, 47 C.F.R.  63.18
(e)(1), to all foreign points as authorized by the
Commission and (2) operates as a resale carrier pursuant to
the terms and conditions of Section 63.18 (e)(2) of the
Commission's Rules to all foreign points as authorized by
the Commission. 47 C.F.R.  63.18 (e)(2). XYZ has no
affiliation with any foreign carrier in any of the
destination countries for which authority is requested nor
is XYZ affiliated with any dominant U.S. carrier whose
services XYZ may resell. Thus, pursuant to Section 63.10
(a)(1) of the Commission's Rules, 47 C.F.R.  63.10 (a)(1),
XYZ should be classified as a non-dominant carrier in its
provision of international service on all routes.
Furthermore, as explained herein, this Application is
entitled to streamlined processing under Section 63.12 of
the Commission's Rules. 47 C.F.R.  63.12. According to the
FCC's fee schedule, Fee Code CUT, a check in the amount of
(applicable fee) is attached hereto.

     In support of its request for authority, XYZ submits
the following information pursuant to Section 63.18 of the
Commission's Rules, 47 C.F.R.  63.18.

     (a)  The name, address and telephone number of the
Applicant is:

     XYZ, Inc.
     120 Elm Street
     Smallsville, Virginia 22021
     (703) 555-5555

     (b)  XYZ is a corporation organized under the laws of
the state of Delaware.

     (c)  Correspondence concerning this Application should
be addressed to:
     
     Joseph Street, Esq
     Lawyer and Son
     200 Oak Street
     Washington, D.C. 20000
     (202) 555-1234

with copies to:

     Steven Smith, President
     XYZ, Inc.
     120 Elm Street
     Smallsville, Virginia 22021
     (703) 555-555

     (d)  XYZ has not previously received Section 214
authority from the Commission.

     (e)  XYZ is applying for authority to operate as a
facilities-based carrier pursuant to the terms and
conditions of Section 63.18 (e)(1), of the Commission's
Rules 47 C.F.R.  63.18 (e)(1) and as a resale carrier
pursuant to the terms and conditions of Section 63.18 (e)(2)
of the Commission's Rules. 47 C.F.R.  63.18 (e)(2). XYZ
requests authority to serve all countries permitted under a
grant of global authority. As evidenced by the certification
provided in Attachment A, XYZ will comply with the terms and
conditions contained in Section 63.21, 63.22 and 63.23 of
the Commission's Rules. 47 C.F.R. 63.21-.23.

     (f)  At this time, Applicant does not seek authority to
provide service not referenced under paragraph (e) of
Section 63.18 of the Commission's Rules. 47 C.F.R.  63.18
(e).

     (g)  XYZ will use previously authorized facilities to
provide the services requested by the Application.
Consequently, XYZ is categorically excluded from
environmental assessment pursuant to Section 1.1306 of the
Commission's Rules. 47 C.F.R.  1.1306.
     
     (h)  XYZ is 90 percent owned by ABC Limited ("ABC"), a
large Australian financial institution, and two other non-
telecommunications Australian-based entities and
individuals. No entity or individual other than ABC has 10
percent or more ownership interest in XYZ. The address of
AMP is 55 Alfred Street, Sydney, NSW, 2000 Australia.

     (i)  As evidenced by the certification attached hereto
as Attachment A, XYZ is not affiliated with a foreign
carrier.


     (j)  As evidenced by the certification attached hereto
as Attachment A, XYZ does not seek to provide international
telecommunications service to any destination where: (1) XYZ
is a foreign carrier in that country; (2) XYZ controls a
foreign carrier in that country; (3) any entity that owns
more than a 25% interest in XYZ, or controls XYZ, controls a
foreign carrier in that country; or (4) two or more parties
own, in the aggregate, more than 25% of XYZ and are parties
to, or the beneficiaries of, a contractual relationship that
affects the provision or marketing of international basic
telecommunications services in the United States.


     (k)  Not applicable; XYZ is not affiliated or otherwise
related to any foreign carrier on any of the routes which
XYZ proposed to provide service in this Application.


     (l)  Not applicable; XYZ is not a foreign carrier and
is not affiliated with a foreign carrier on any of the
routes it proposes to resell international
telecommunications service.


     (m)  Not applicable; XYZ is not affiliated with any
foreign carrier on nay of the routes it proposes to provide
services.
     
     (n)  As evidenced by the certification provided in
Attachment A, XYZ has not agreed to accept special
concessions directly or indirectly from any foreign carrier
with respect to any U.S. international route the foreign
carrier possesses sufficient market power on the foreign end
of the route to affect competition adversely in the U.S.
market and will not enter into such agreements in the
future.

     (o)  As evidenced by the certification provided in
Attachment A, no party to this application is subject to a
denial of Federal benefits pursuant to Section 5301 of the
Anti-Drug Abuse Act of 1988.

     (p)  XYZ respectfully requests streamlined processing
of this Application pursuant to Section 63.12 of the
Commission's Rules. 47 C.F.R.  63.12. This Application
qualifies for streamlined processing for the following
reasons: (1) XYZ is not affiliated with a foreign carrier on
any route for which authority is sought; (2) XYZ is not
affiliated with any dominant U.S. carrier whose
international switched or private lines services it seeks to
resell; and (3) XYZ is not requesting authority to provide
switched service over private lines to countries not
previously authorized for service by the Commission.

     Wherefore, XYZ respectfully requests that the
Commission grant it authority to provide international
telecommunications services on a facilities and resale basis
pursuant to Section 214 of the Communications Act of 1934,
as amended.

                         Respectfully submitted,

                         XYZ, Inc.
                         
                         By: _______________________
                         Steven Smith, President
                         XYZ, Inc.
                         120 Elm Street
                         Smallsville, Virginia 22021
                         (703) 555-5555

                         Date: _____________________





                         CERTIFICATE


     The undersigned hereby certifies, on behalf of XYZ,
Inc. ("XYZ") with respect to the foregoing application for
authority to provide international services, that:


     1.   XYZ is not affiliated with any foreign carrier in
any of the countries to which XYZ proposes to provide
service in the foregoing application.

     2.   XYZ will comply with the terms and conditions
contained in Section 63.21, 63.22 and 63.23 of the
Commission's Rules. 47 C.F.R. 63.21-.23

     3.   XYZ does not seek to provide international
telecommunications service to any destination where: (1) XYZ
is a foreign carrier in that country; (2) XYZ controls a
foreign carrier in that country; (3) any entity that owns
more than a 25% interest in XYZ, or controls XYZ, controls a
foreign carrier in that country; or (4) two or more parties
own, in the aggregate, more than 25% of XYZ and are parties
to, or the beneficiaries of, a contractual relationship that
affects that provision or marketing of international basic
telecommunications services in the United States.

     4.   XYZ has not agreed to accept special concessions
directly or indirectly from any foreign carrier with respect
to any U.S. international route where the foreign carrier
possesses sufficient market power on the foreign end of the
route to affect competition adversely in the U.S. market and
will not enter into such agreements in the future.

     5.   No party to this application is subject to a
denial for Federal benefits pursuant to Section 5301 of the
Anti-Drug Abuse Act of 1988, 21 U.S.C.  853 (a).



                         By: ____________________________
                         Title: ____________________________
                         Date: ____________________________