Attachment FCC Form 159

This document pretains to SES-ASG-20150615-00363 for Assignment on a Satellite Earth Station filing.

IBFS_SESASG2015061500363_1086626

READ INSTRUCTIONS CAREFULLY Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMISSION 3060-0589 REMITTANCE ADVICE 1 of__ Page No__ (1) LOCK BOX # SPECIAL USE ONLY FCC USE ONLY SECTION A – PAYER INFORMATION (2) PAYER NAME (if paying by credit card enter name exactly as it appears on the card) (3) TOTAL AMOUNT PAID (U.S. Dollars and cents) Cinnamon Mueller LLC $560.00 (4) STREET ADDRESS LINE NO.1 307 N. Michigan Avenue (5) STREET ADDRESS LINE NO. 2 Suite 1020 (6) CITY (7) STATE (8) ZIP CODE Chicago IL 60601 (9) DAYTIME TELEPHONE NUMBER (include area code) (10) COUNTRY CODE (if not in U.S.A.) 312-372-3930 FCC REGISTRATION NUMBER (FRN) REQUIRED (11) PAYER (FRN) (12) FCC USE ONLY 0005-8529-34 IF MORE THAN ONE APPLICANT, USE CONTINUATION SHEETS (FORM 159-C) COMPLETE SECTION BELOW FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET (13) APPLICANT NAME MetroCast Communications of Mississippi, LLC (14) STREET ADDRESS LINE NO.1 70 East Lancaster Avenue (15) STREET ADDRESS LINE NO. 2 (16) CITY (17) STATE (18) ZIP CODE Frazer PA 19355 (19) DAYTIME TELEPHONE NUMBER (include area code) (20) COUNTRY CODE (if not in U.S.A.) 610.993.1024 FCC REGISTRATION NUMBER (FRN) REQUIRED (21) APPLICANT (FRN) (22) FCC USE ONLY 0016984981 COMPLETE SECTION C FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET (23A) CALL SIGN/OTHER ID (24A) PAYMENT TYPE CODE (25A) QUANTITY E3921 CNO 1 (26A) FEE DUE FOR (PTC) (27A) TOTAL FEE FCC USE ONLY $560.00 $560.00 (28A) FCC CODE I (29A) FCC CODE 2 (23B) CALL SIGN/OTHER ID (24B) PAYMENT TYPE CODE (25B) QUANTITY (26B) FEE DUE FOR (PTC) (27B) TOTAL FEE FC C USE ONLY (28B)FCC CODE I (29B) FCC CODE 2 SECTION D – CERTIFICATION CERTIFICATION STATEMENT I, , certify under penalty of perjury that the foregoing and supporting information is true and correct to the best of my knowledge, information and belief. SIGNATURE _______________________________________________________________ DATE _________________________ SECTION E - CREDIT CARD PAYMENT INFORMATION MASTERCARD______ X VISA_______ AMEX_______ DISCOVER_______ 4802138512103110 ACCOUNT NUMBER_____________________________________________________ 05/16 EXPIRATION DATE ____________________________________ I hereby authorize the FCC to charge my credit card for the service(s)/authorization herein described. SIGNATURE__________________________________________________________________________ DATE_____________________________________ SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003(REVISED)


Document Created: 2015-04-28 17:29:19
Document Modified: 2015-04-28 17:29:19
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