Attachment F159

This document pretains to SES-STA-20121016-00931 for Special Temporal Authority on a Satellite Earth Station filing.

IBFS_SESSTA2012101600931_971140

READ INSTRUCTIONS CAREFULLY Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMISSION 30600589 REMITTANCE ADVICE Page No_1 of 2 FORM 159 (1)LOCKBOX # SPECIAL USE ONLY 979097 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) BFMTV $175.00 (4) STREET ADDRESS LINE NO.1 12 RUE D‘ORADOUR SUR GLANE (5) STREET ADDRESS LINE NO. 2 (6) CITY (7) STATE (8) ZIP CODE PARIS 75015 (9) DAYTIME TELEPHONE NUMBE-R (include area code) (10) COUNTRY CODE (if not in U.S.A.) +33171193470 FR FCC REGISTRATION NUMBER (FRN) REQUIRED (11) PAYER (FRN) (12)FGC U-SE ONLY 0020995072 IF MORE THAN ONE APPLICANT, USE CONTINUATION SHEETS (FORM 159—C) _ COMPLETE SECTION BELOW FOR EACH SERYICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET (13) APPLICANT NAME BFMTV (14) STREET ADDRESS LINE NO 1 12 RUE D‘ORADOUR SUR GLANE (15) STREET ADDRESS LINE NO 2 Tieyciny (M)STATE (i8)Zip cope PARIS 75015 (19) DAYTIME TELEPHONE NUMBER (include area code) T20)JCOUNTRY CODE (if not in U S A ) +33171193470 FR TCC RECISTRATION NUMBER (FRN) REouiRED T1 APPLICANT(ERN) Cz FcC UsE onLy 0020995072 COMPLETE SECTION C FOR EACH SERVICE, IF MORE BoOXES ARE NEEDED, USE CONTINUATION SHEET C3A)CALL stGNrotiEr iD UCiA)PAYMENT TYPE CODE SA)GUANTITY PAOM 1 (26A) FEE DUE FOR (PTC) (27A) TOTAL FEE TCC USE OnLY $175.00 (2BA) FCC CODE I (29A) FCC cope 2 commues mm (3B)CALL SIGN/OTHER ID (CaB)PAYMENT TYPE CODE (25B) QUANTITY (26B) FEE DUE FOR (PTC) (278) TOTAL FEE TCC USE ONLY smnnammemmen (SB)FCC CODE I (29B) FCC CODE 2 SECTION D — CERTIFICATION CERTIFICATION STAIEMENT I , certify under penalty ofperjury that the foregoing and supporting information is true and correct to the best of my knowledge, information and belief a SIGNATURE DATE_AO_'[ASlbl 2— SECTION E — CREDIT CARD PAYMENT INFORMATION MASTERCARDX VISA AMEX DISCOVER_ ACCOUNT NUMBER‘fi&,—_Mm& EXPIRATION DATE M LA_L_ I hereby authorize the FCORo gharge my credit card for the service(s/authorization herein described. SIGNATURE mrMS]ZolIZ. _ SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003


Document Created: 2012-10-15 18:45:08
Document Modified: 2012-10-15 18:45:08
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