West Virginia Code of State Rules
Agency 150 - Public Service Commission
Title 150 - EXEMPT LEGISLATIVE RULE PUBLIC SERVICE COMMISSION
Series 150-21 - Certification of Operation of Telecommunication Relay Services (TRS)
Section 150-21-9 - Service and operational standards

1. Applicant's full name and address:

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

2. Applicant's Telephone number: _______________________________________________________________

3. Applicant's Tax ID numbers: Federal: ___________________ West Virginia: _______________________

4. If applicant is owned or controlled by a parent company, provide the information required in paragraphs 1 through 3 above for the parent.

Name and Address: ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Telephone number: __________________________

Tax ID numbers: Federal: _______________________________ West Virginia:__________________________

Application of________________________________________________________________________________.

5. Specific location(s) of TRS facility:

___________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

_________________________________________________________________________________________

6. Provide the date proposed by the applicant for initiation of service under the certificate:

___________________________________________________________________________________________

Form 5.1, page 2

Application of ___________________________________________________________.

7. If the applicant, or an affiliate, presently operates any TRS facility, this Application must include attachments listing the location of such facility(ies) and the names, titles, addresses and telephone numbers of contact persons for each facility at the State's equivalent to the PSC.

8. Provide an organizational chart showing the staffing and lines of authority for key personnel to be used, including subcontractors. Also provide a complete description of the personnel, including supervisory personnel, necessary for increasing levels of call volumes and a discussion as to how such personnel will be screened, selected and trained.

9. Provide the following financial information for the applicant, its parent company (if applicable) and any contractor or subcontractor which is expected to receive ten percent (10%) or more of the total revenues from the service (if applicable):

10. Provide a statement detailing applicant's managerial expertise in the telecommunications industry and in dealing with the deaf, hearing impaired and speech impaired communities.

11. Provide a statement detailing applicant's technical expertise in the telecommunications industry and in dealing with telecommunications as related to the deaf, hearing impaired and speech impaired communities.

12. Attach a complete description of the TRS facilities to be used, the general staffing and operations of the facilities and any problems and solutions to said problems the applicant perceives in providing full TRS in compliance with all requirements of the Public Service Commission.

13. Appendix A to this form provides a full and complete description of operational, technical and functional standards required by the Public Service Commission. Applicant must address, on attachments hereto, the standards set by the Commission and clearly describe how the applicant will meet or exceed these standards. Mandatory standards must be met under all circumstances. Required standards must be met unless specifically waived by the Commission in the Order granting the certificate. Enhancements will be considered by the Commission in determining the desirability of each application for TRS.

14. Attach a complete description of the rates and charges proposed by the applicant. Rates must be structured on a per minute basis for the time (measured in fractional minutes) necessary to complete a call. This time shall include call set-up, call wrap-up and actual conversation time. Proposed rates must be structured as follows:

Form 5.1, page 3.

Enhanced functions and any proposed outreach to customers should be priced separately and include a description of how these enhancements will be furnished.

(Add a verification page signed by an authorized officer of applicant. Verification must indicate an understanding and full agreement to comply with the provisions of paragraph 6 of the Commission's Rules Governing Certification and Operation of Telecommunication Relay Service.)

VERIFICATION

State of West Virginia

County of Kanawha, ss.

____________________________, a duly authorized representative of ___________________________________, the Applicant named in the foregoing application, being duly sworn says that the facts and allegations therein contained are true except so far as they are therein stated to be on information, and that, so far as they are therein stated to be on information, he/she believes them to be true.

________________________________________________

Affiant

Taken, sworn to and subscribed before me this the _______ day of __________________, 2_____.

________________________________________

Notary Public in and for said County

My commission expires on the ______ day of _____________, 2_____.

Appendix A to

PSC FORM 5.1