Application Form [pdf]

This document pretains to ITC-214-INTR2009-07572 for International Global Resale Authority on a International Telecommunications filing.

IBFS_ITC214INTR200907572_782438

Approved by OMB 3060−0686 INTERNATIONAL SECTION 214 APPLICATION FCC FORM 214 FOR OFFICIAL USE ONLY APPLICANT INFORMATION Enter a description of this application to identify it on the main menu: Medallion Telecom 1. Applicant Name: Medallion Telecom, Inc. Phone Number: 818−749−5442 DBA Fax Number: 818−484−2118 Name: Street: 1717 N. Verdugo Rd. #183 E−Mail: gary@medalliontelecom.com City: Glendale State: CA Country: USA Zipcode: 91208 − Attention: Mr Gary Khechoom 1

2. Contact Name: Gary Khechoom Phone Number: 818−749−5442 Company: Medallion Telecom, Inc. Fax Number: 818−484−2118 Street: 1717 N. Verdugo Rd. #183 E−Mail: gary@medalliontelecom.com City: Glendale State: CA Country: USA Zipcode: 91208 − 2940 Attention: Gary Khechoom Relationship: Same 3. Place of Incorporation of Applicant California 4. Other Company(ies) and Place(s) of Incorporation None 5. Service Type(s) (check all that apply) Global or Limited Global Facilities−Based Authority (Section 63.18(e)(1)) Global or Limited Global Resale Authority (Section 63.18(e)(2)) Individual Facilities−Based Service (Section 63.18(e)(3)) Individual Switched Resale Service (Section 63.18(e)(3)) Individual Facilities−Based and Resale Service (Section 63.18(e)(3)) Switched Services over Private Lines (ISR) (Section 63.16 and/or 63.18 (e)(3)) Inmarsat and Mobile Satellite Service (Section 63.18(e)(3)) Overseas Cable Construction (Section 63.18(e)(3)) Individual Non−Interconnected Private Line Resale Service (Section 63.18(e)(3)) Other (Section 63.18(e)(3)) 2

6a. Is a fee submitted with this application? If Yes, complete and attach FCC Form 159. If No, indicate reason for fee exemption (see 47 C.F.R.Section 1.1114). Governmental Entity Noncommercial educational licensee Other(please explain): 6b. Fee Classification CUT − Section 214 Authority 7. Destination Country(ies) (e.g., "Country X", "All international points", "All international points except Country X and Country Y" or "Countries X, Y, and Z only".) All countries 8. Caption (description of authority requested, e.g., Application for Authority to Provide International Facilities−Based and Resold Services to All International Points Except Country X) (If the complete description does not appear in this box, please go to the end of the form to view it in its entirety.) Application for Authority to Provide International Resold Services to All International Points 9. Does the applicant request streamlined processing pursuant to 47 C.F.R. Section 63.12? If yes, include in Yes No Attachment 1 a statement of how the application qualifies for streamlined processing. 10. If applying for authority to provide switched services over private lines pursuant to Section 63.16, provide the required showing in Attachment 1. 3

Applicant certifies that its responses to questions 11 through 17 are true: 11. If the applicant is a foreign carrier, or is affiliated (as defined in 47 C.F.R. Section 63.09(e)) with a foreign carrier, provide in Attachment 1 the information and certifications required by Section 63.18(i) through (m). 12. Does the applicant seek authority to provide service to any destination described in paragraphs (1) through (4) Yes No of Section 63.18(j)? If yes, list those destinations in Attachment 1 as a response to question 12. 13. Does the applicant seek authority to provide service to any destinations other than those listed in response to Yes No question 12 where it has an affiliation with a foreign carrier? If yes, list those destinations in Attachment 1 as a response to question 13. 14. [Section 63.18(h)] In Attachment 2, provide the name, address, citizenship and principal business of the applicant’s ten percent or greater direct and indirect shareholders or other equity holders, and identify any interlocking directorates. 15. In Attachment 2, respond to paragraphs (d), (e)(3) and (g) of Section 63.18. 4

16. By checking Yes, the undersigned certifies that neither applicant nor any other party to the application is subject Yes No to a denial of Federal benefits that includes FCC benefits pursuant to Section 5301 of the Anti−Drug Act of 1988, 21 U.S.C. Section 862, because of a conviction for possession or distribution of a controlled substance. See 47 CFR 1.2002(b) for the meaning of "party to the application" for these purposes. 17. By checking Yes, the applicant certifies that it has not agreed to accept special concessions directly or indirectly Yes No from a 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. CERTIFICATION 18. Typed Name of Person Signing (Must be a Corporate Officer) 19. Title of Person Signing Gary Khechoom President WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND / OR IMPRISONMENT (U.S. Code, Title 18, Section 1001), AND/OR REVOCATION OF ANY STATION AUTHORIZATION (U.S. Code, Title 47, Section 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503). 20. 1: 2: Answers to questions 3: 5

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT The public reporting for this collection of information is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD−PERM, Paperwork Reduction Project (3060−0686), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to PRA@fcc.gov. PLEASE DO NOT SEND YOUR RESPONSE TO THIS ADDRESS. Remember − You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060−0686. THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104−13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507. 6


Document Created: 2019-04-23 20:00:41
Document Modified: 2019-04-23 20:00:41
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