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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