Appendix III
Form 4
AUTHORIZATION FOR POLE MAKE-READY WORK
Licensee__________________________________________________________________
Field survey work associated with your License Application No._________________ dated ______________, for attachment to poles, in the municipality of _____________________, State of________________ has been completed. Following is a summary of the make-ready charges which will apply:
| TASK # |QUANTITY |UNIT COST |TOTAL COST |
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|Custom Work Order Preparation | | | |
|Miscellaneous | | | |
Attached, as requested, is an itemized unit cost (Form 3) of required make-ready work and associated charges. If you wish us to complete the required make-ready work, please sign this copy below and return with an advance payment in the amount of $________________.
Licensor’s Name (Print)___________________
Signature ______________________________
Title _________________________________
Address ______________________________
Tel. No _______________________________
Date ________________________________
The replacements and rearrangements included in Pole Attachment License Application
No.___________________are authorized and the costs therefore will be paid to Licensor in accordance with Appendix I to Pole Attachment License Agreement. My check is attached.
Licensee's Name (Print) ______________________________________________________
Signature ____________________________________ Tel. No._______________________
Title Date _______________________
Additional Sheet Form 4 p.2
Licensee__________________________________________________________________
Field survey work associated with your License Application No.________________________ dated____________, for attachment to poles, in the municipality of ____________________,
State of__________________ has been completed. Following is a summary of the make-ready charges which will apply:
|TASK # |QUANTITY |UNIT COST |TOTAL COST |
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|Custom Work Order Preparation | | | |
|Miscellaneous | | | |
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