For the work to be performed in the certified te rritory of _________________(Telco Name)
State of ________________County of ___________________________
I.________________________(name),___________________________________(business address)
______________(telephone number) representing ______________________(name of customer), a customer located at
_____________________(address) _________(telephone number) being duly sworn: state:
I have the responsibility for the operation and maintenance of the terminal equipment to be connected to _________ 1.544
Mbps and/or _________ Subrate dig ital services. The terminal equipment to be connected complies wi th Para. 68 of the FCC
rules except for the encoded analog content and billing protection spe cifications. With respect to encoded analog content and
billing protection.
() I attest that all operations assoc iated with the establishment, maintenance, and adjustment of the
digital CPE with respect to encoded analog content and encoded billing protection information
continuously complies with Part 68 of the FCC Rules and Regulations.
() The digital CPE does not transmit digital signals containing encoded analog content or billing
information which is intended to be decoded wit h the telecommunications network.
() The encode analog content and billing protection is factory set and is not under the control of the
customer.
I attest that the operator(s )/maintainer(s) of the dig ital CPE responsible for the establishment, mainten ance, and adjustment of
the encoded analog content and billing information has (have) been trained to perform these functions by successfully having
completed one of the following (Check appropriate block).
() a. A training course provided by the manufactu rer/gra ntee of the e quipment use d t o enc ode analog signal(s); or () b. A training course provided by the customer of authorized representative, using training materials
and instructions provided by the manufacture/grantee of the used to encode analog signal(s); or
() c. An independent training course (e.g. trade school or technical institution) recognized by the
manufacturer/grantee of the equipmen t used to encode analog signal(s); or
() d. In lieu of the proceeding training requirements , the operator(s)/maintainer(s) is (are) under the
control of a supervisor trained in accord ance with ________ (circle one) above.
I agree to provide _______________ (Telco’ s name) with proper documentation to demonstrate compliance with the
information as provide d in the preceding paragra phs, if so requested.
_________________(Signature)
________________(title)
__________(date)
Subscribed and Sworn to before me
this ____ day of _____, 19__
_________________________
Notary Public
My commission expires:________________