Attachment Form 159

This document pretains to SAT-MOD-20040405-00078 for Modification on a Satellite Space Stations filing.

IBFS_SATMOD2004040500078_371068

ORIGINAL READ INSTRUCTIONS CAREFULLY * mku aPR492004 Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMlSSlON 30600589 REMITTANCE ADVICE Page 1- of_! ( I ) LOCKBOX I 358210 SECTION A-PAYERINFORMATION (2) PAYERNAME (if paying by credit card enter name exactly as it appears onthe card) (3) TOTAL AMOUNT PAID (U S Dollars and cents) PanAmSat Licensee Cortl. $7.050.00 I (4) STREET ADDRESS LINE NO I 1801 K Street. N.W. ( 5 ) STREET ADDRESS LINE NO 2 Suite 440 (6) CITY (7) STATE (8) ZIP CODE Washinaton DC 20006 (9)DAYTIME TELEPHONE NUMBER (include areacode) I ( I O ) COUNTRY CODE (if notin U S A ) - 202 2924300 F C C REGISTRATION NUMBER IFRN) REQUIRED [II)PAYCRltRU) (12)FeUSEQNk.Y 0005848577 F \ l O.~ I. R E THAY O N E A P P L l C A h T USE CONTIYL'ATIOY S H E E T S ( F O R h 1 159-CI COMPLETE SECTIONBELOW FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET ( I 3) APPLICANT NAME PanAmSat Licensee Corix ~~~ (I~)STREETADDRESSLINEO I ~ 1801 K Street, N.W. ( 15) STREET ADDRESS LINE NO 2 Suite 440 (1 6) CITY 1 (17)STATE 1 (l8)ZIPCODE Washinaton 1 DC 20006 - (I9)DAYTIME TELEPHONE NUMBER (include area code) 1 (20) COUNTRY CODE (if not in U S A ) 202-292-4300 F C C REGISTRATION NUMBER(FRN) REOUIRED ( 2 I j \ P P I ICAUT[FRI\) (21)FCCUSE ONLY 0005848577 C O M P L t l I.' SEC TlOY C FOR EAC H SLRVICL. I F MORL BOXES ARE YELDED, LSI. COhTIYUATIOY S l l E L l (23A) CALL SIGN/OTHER ID (24A)PAYMENTTYPE CODE (25A) QUANTITY BFY I I?bAjtt:E DLEI'OR(P1C) 67.050.00 (2b.A) FCC CODE I I $7,050.00 (2"Al F('CCOI)E? -. I 182004000724 (238) CALL SlGN/OTHER ID (24B) PAYMENT TYPE CODE (25B) QUANTITY SECTION D- CERTIFICATION CERTIFICATION STATEMENT I. , certify under penalty ofperjury that the foregoing and supporting information is true and correct to the best o f m y knowledge, information and belief SIGNATURE DATE S E C T I O N E CREDIT CARD PAYMENT INFORMATION ~ MASTERCARD- VISA- AMEX- DISCOVER- ACCOUNT NUMBER EXPIRATION DATE I hereby authorize the FCC to charge my credit card for the service(s)/authorizatim herein described SIGNATURE DATE SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003(REVISED)


Document Created: 2004-04-29 14:28:04
Document Modified: 2004-04-29 14:28:04
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