Application Form

This document pretains to ITC-STA-20101001-00390 for Special Temporal Authority on a International Telecommunications filing.

Approved by OMB
3060-0686
INTERNATIONAL SECTION 214 SPECIAL TEMPORARY AUTHORITY APPLICATION
FCC FORM 214STA
 FOR OFFICIAL USE ONLY

APPLICANT INFORMATION

Enter a description of this application to identify it on the main menu:
Tricom USA, Inc. Request for New Special Temporary Authority, or in the alternative, extension of Special Temporary Authority.
1. Applicant
TRICOM USA, INC. 809-476-4912
809-412-2841
One Exchange Place
SUITE 311
JERSEY CITY NJ
USA 07302 -
Mr Marc Rene Rocher
2. Contact
Michelle Cohen 202-263-4151
Thompson Hine LLP 202-331-8330
1920 N Street, NW [email protected]
Washington DC
USA 20036 -
Legal Counsel
3. Place of Incorporation of ApplicantDelaware
4. Other Company(ies) and Place(s) of Incorporation
Broadband Investments Limted, a Barbados limited Liability company
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))

TYPE OF REQUEST

6. New Request Extend STA Date Other 7. Date Authorization Needed:10/03/2010
8.
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):
9. Description of Special Temporary Authority Requested.
Tricom USA, Inc. Request for New Special Temporary Authority, or in the alternative, extension of Special Temporary Authority.
10. In Attachment 1, provide justification of need for special temporary authority requested.
11. If this request for Special Temporary Authority is associated with any pending applications filed with the Commission, enter either the file number [e.g., ITC-214-19930101-23412] or the IB Submission ID of the pending application [e.g., IB200311111] AND go to question 16.)
File Number ITCT/C2010071900295 or Submission ID

Applicant certifies that its responses to questions 11 through 17 are true:

12. 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).
13. Does the applicant seek authority to provide service to any destination described in paragraphs (1) through (4) of Section 63.18(j)? If yes, list those destinations in Attachment 1 as a response to question 12. Yes No
14. Does the applicant seek authority to provide service to any destinations other than those listed in response to 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. Yes No
15. [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.
16. In Attachment 1, respond to paragraphs (d), (e)(3) and (g) of Section 63.18.
17. By checking Yes, the undersigned certifies that neither applicant nor any other party to the application is subject 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. Yes No
18. By checking Yes, the applicant certifies that it has not agreed to accept special concessions directly or indirectly 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. Yes No

CERTIFICATION

19. Typed Name of Person Signing
Bela Szabo		 20. Title of Person Signing
Vice President, International Business
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).
21. 1: Attachment 1 2: Attachment 2 3:


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