Attachment Form 159

This document pretains to SAT-MOD-20040405-00079 for Modification on a Satellite Space Stations filing.

IBFS_SATMOD2004040500079_371067

ORIGINAL READ INSTRCCTIONS CAREFULLY BEFORE PROCEEDING PanAmSat Licensee Corm (14) STREET ADDRESS LINENO 1 1801 K Street, N.W. (15) STREET ADDRESS LINENO 2 Suite 440 ( I 6) CITY I (I7)STATE I (18)ZIPCODE Washinnton ( I 9) DAYTIME TELEPHONE NUMBER (include area code) I DC 20006 - (20)COUNTRY CODE (tfnot in U SA ) 202-292-4300 us . F C C REGISTRATION NUMBERIFRN),REOIITRED - _ - - -- ( 2 1 ) APPLICANT(FRU) [2Z) FCe 1358ONLY 0005848577 C O M P L E T E S E C T l O l C FOR E \CH SEKVICE. l k MORE BOYFS \RL \EEDED. llSE CONTIhLlATIOY S l l F E l (23A) CALL SIGNIOTHER ID (24A) PAYMENT TYPE CODE ( E A ) QUANTITY BFY 1 $7.050.00 I lB2004000725 (23B) CALL SIGNIOTHER ID (248) PAYMENT TYPE CODE (25B) QUANTITY SECTION D - CERTIFICATION C L K l l F l C A l l U N SI A I & M L N I I, cenify under penalty ofperjuiy that the foregoing and supporting Informatton is true and correct to the best of my knowledge, information and bellef SIGNATURE DATE SECTION E C R E D l T CARD PAYMENT INFORMATION ~ MASTERCARD- VISA- AMEX- DISCOVER- ACCOUNT NUMBER EXPLRATION DATE I hereby authorize the FCC to charge my credit card for the service(s)/authonzatia herein described SIGNATURE DATE SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003(REVISED)


Document Created: 2004-04-29 14:28:43
Document Modified: 2004-04-29 14:28:43
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