Tennessee Regulatory Authority
460 James Robertson Parkway
Nashville, TN 37243-0505
Telephone Solicitor Registration Application
Application is hereby made to obtain access to the Tennessee “Do-Not-Call Register” pursuant to TRA Rule 1220-4-11-.04 Registration submitted for July 1, 2012 – June 30, 2013. Please print or type the information requested below.
Federal Taxpayer ID or SS# of Applicant ____________________ Check one: New Registration _____ Re-registering_____
Name of Your Company
__________________________________________________________________________________________________
Legal name of corporation, partnership, or proprietorship for which application is made.
________________________________________________________________________________________________________________________
Business or individual name used when contacting the public.Trade name(s), assumed name(s) or fictitious names used.
Nature of Business_______________________________________________________________________________________________________
This registration is for: _______ Standard Registration ________Principal Solicitor (mark one with X)
Choose one: Delivery by E-mail of the DNC List: email address________________________ For delivery by CD check here__________
Contact person for inquiries from the TRA. (Mailing address for contact must be within US borders; phone numbers must be US area codes or toll free numbers. This is the only person authorized to make changes to your company information. This person is responsible for keeping all application information on file, correct and updated with the TRA.
Phone #______________________ Fax #___________________ E-mail Address ________________________________
__________________________________________________________________________________________________
Designated Contact Name |
Address |
City |
State Zip Code |
Person authorized to respond to notices of alleged violations from TRA.
Phone #______________________ Fax #____________________ E-mail Address_______________________________
__________________________________________________________________________________________________
Name of authorized person |
Address |
City |
State Zip Code |
Is applicant utilizing ADADs or predictive dialers for calls originating or terminating in Tennessee? |
Yes____ No _____ |
Provide the telephone number(s) for responding to inquiries relative to the telephone solicitation during hours when |
telephone solicitations are being made. Toll Free ( |
)____-__________. |
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Provide name, address and telephone number of Telemarketer if your telemarketing is being outsourced:
__________________________________________________________________________________________________
Name of Company Contact Person AddressCity StateTelephone number
Provide the name, address and telephone number of the Registered Agent for Service of Process. (must be located in Tennessee)
__________________________________________________________________________________________________
Name |
Address |
City |
State Zip Code |
Telephone # |
email address |
PS-0376 (REV 4/10) |
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On a separate sheet of paper marked as supplemental attachment 2, list the name, address and telephone number of all subsidiaries and affiliate companies associated with your company which will have access to your Do-Not-Call Register. An affiliate company is one that your company effectively controls because of its ownership interest. A subsidiary company is one as to which your company owns more than 50% of the voting shares.
If you are registering as a Principal Solicitor, submit a supplemental attachment 1 with this application.
FEE:
1.If you marked standard registration, mail the completed application (original) along with any attachments thereto including a certified cashier’s check or money order for $500.00 to: Tennessee Regulatory Authority, Attn: DO-NOT-CALL REGISTER, 460 James Robertson Parkway, Nashville TN 37243-0505.
2.If you marked Principal Solicitor, mail the completed application including a certified cashier’s check or money order in the amount of $1,000.00 and an additional $50.00 for each independent solicitor listed on the supplemental attachment 1 to: Tennessee Regulatory Authority, Attn: DO-NOT-CALL REGISTER, 460 James Robertson Parkway, Nashville TN 37243-0505.
Compliance Statement:
The Tennessee “Do-Not-Call Register” telephone solicitor applicant, hereby, affirms the following:
I/We will comply with the Tennessee Regulatory Authority’s (“TRA”) Rules and Regulations Chapter 1220- 4-11 and all other applicable state laws, including but not limited to T.C.A. Section 65-4-401, et seq.
I/We will notify the Tennessee Regulatory Authority within thirty (30) days of any material change relative to this application or the information contained therein.
Having been duly sworn, and under the penalties of perjury, I hereby certify that the representations in the APPLICATION and all attachments are true and correct to the best of my knowledge and belief.
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SIGNATURE |
______________________________________________ |
_________________________________ |
NAME OF APPLICANT-COMPANY NAME |
PRINTED NAME |
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_________________________________ |
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TITLE |
Subscribed and sworn to or affirmed before me, this __________day of _________________________ , _____________________.
Day |
Month |
Year |
Known to be the person named in, and who executed the foregoing application. |
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My commission expires on ________________________. |
_________________________________________ |
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Signature of Notary and Authorized Official |
Seal
Additional information on the Do-Not-Call Program, including a copy of the Program’s Rules and Regulations, can be obtained from the TRA Webpage
located at www.tn.gov/tra. All questions regarding the information on this application should be referred to (615)741-3939, ext. 162.
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PS-0376 (REV 4/10)
