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0462-800 ELECTRIC SERVICE PROVIDER REGISTRATION APPLICATION FORM ***PLEASE PRINT OR TYPE*** ESP No. ______________________ 1. Exact Legal Name of Registrant: ________________________________________________________________ If registrant is conducting business in California under a fictitious business name, list all the names under which the registrant is doing business as (DBA) in California, and the date and county in which the fictitious business name statement was filed. (Attach additional page if necessary.) For each DBA, provide a copy of the proof of publication of the fictitious business name, or a copy of the certified fictitious business name statement. (See Business & Professions Code Sections 17910, 17917, 17926.) ________________________________________________ ___________________ ______________________________ DBA Date County ________________________________________________ ___________________ ______________________________ DBA Date County ________________________________________________ ___________________ ______________________________ DBA Date County ________________________________________________ ___________________ ______________________________ DBA Date County 2. Current Address: ___________________________________________________________________________________________________ Address ___________________________________________________________________________________________________ City State Zip Code 3. Current Telephone Number: ______________________________________________________________________ 4. Type of Ownership: ❒ Individual ❒ ❒ Partnership Government Entity Complete and mail this application along with $100.00 certified check (write 0462-800 on front of check) and complete fingerprint cards (see question no. 21 to: State of California Public Utilities Commission Energy Division - ESP Registration 505 Van Ness Avenue San Francisco, CA 94102-3298 ❒ Corporation ❒ ❒ Limited Liability Company Other INCOMPLETE APPLICATIONS CANNOT BE PROCESSED FOR CPUC USE ONLY Application Processed By: ________________________ Date: ________________________ Page 1 of 7 Rev. 8/03 5. If a non-California corporation, limited liability company, or limited partnership, attach a copy of the certificate from the California Secretary of State permitting the entity to transact business in California. (See Corporations Code Sections 2105, 15692, 17451.) 6. a. If registrant is a corporation, the state in which the registrant is incorporated and date of incorporation:____________________________(State of Incorporation) _______________(Date) b. List names and titles of corporate officers. (Attach additional page if necessary): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 7. If a partnership list all general partners. (Attach additional page if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 8. If a limited liability company list all managers and/or officers and their titles. (Attach additional page if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 9. If registrant has listed type of ownership as “government entity” provide a brief description of the government entity, and list the names and titles of the personnel responsible for managing the sale of electricity to residential and small commercial customers. (Attach additional page if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 10. If registrant has listed type of ownership as “other” describe the type of ownership, list the names and titles of all managers or officers, and attach a copy of the document establishing the entity as well and the bylaws or similar governing document of the entity. (Attach additional page if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Page 2 of 7 Rev. 8/03 11. If the type of ownership is a corporation, provide a listing of the name and address of all persons or entities that directly or indirectly own, control, or hold the power to vote ten percent or more of the outstanding voting securities of the registrant. In the alternative, attach any report required by the Securities and Exchange Commission which details such an interest. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 12. List all of the names and addresses of all the corporate registrant’s affiliates in which the registrant owns, controls or hold five percent or more of the affiliate. If this information is contained in any report required by the Securities and Exchange Commission, that report may be submitted in lieu of the information. See the “NOTICE” section for the definition of an “affiliate.” _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 13. The street address and telephone number of the registrant’s principal place of business, if DIFFERENT from current address and telephone number listed in line numbers 2 and 3: ____________________________________________________________________________________________________ Street Address ____________________________________________________________________________________________________ City State Zip Code ____________________________________________ Telephone Number 14. a. Please provide a brief description of the electrical services you plan to offer. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ b. Check the box or boxes which best describe your business. (See P.U. Code Section 331.) ❒ Marketer ❒ Aggregator ❒ Broker c. Check the box or boxes which describe what customer classes you plan to serve. ❒ ❒ ❒ Residential Customers ❒ Small Commercial Customers Medium to Large Commercial Customers Industrial Customers d. Check the box or boxes which best describe the geographic area in which you plan to offer electrical services. Page 3 of 7 Rev. 8/03 ❒ ❒ Statewide Central California Counties ❒ ❒ Northern California Counties Southern California Counties e. Indicate the number of customers you plan to serve. ___________ f. Indicate the average number of kWhs you expect to provide per month. ___________ 15. Before you can apply to register as an electric service provider (ESP), you are required to execute a service agreement with each utility distribution company (UDC) in whose service territory you plan to do business. State the name of each UDC for which you have a signed UDCESP service agreement. Attach to this form an executed copy of each UDC-ESP agreement. Name of UDCs: ____________________________________________________________________________________ 16. a. Provide the names and titles of the key personnel that are involved in the technical and operational aspects of the business. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ b. On a separate attachment, describe each key person’s experience in the sale, procurement, metering, and billing of energy sources or similar products, including the time period of such experience. ESPs may submit resumes of the key technical and operational personnel if the resume includes the requested information. c. If your company is not providing metering or billing services, provide the names of the companies who will provide those services on your behalf, and provide a description of their experience in those areas. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 17. Has your company been authorized by the California Independent System Operator to act as a scheduling coordinator? ❒ No ❒ Yes If yes, attach a copy of such authorization. 18. The name, title, address and telephone number of the person to whom correspondence or communication regarding customer complaints or inquiries are to be addressed. ____________________________________________________________________________________________________ Name Title ____________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City State Zip Code ____________________________ Telephone Number _____________________________ FAX Number (If available) Page 4 of 7 Rev. 8/03 ______________________________________ E-Mail Address (If available) 19. Name and Address of Agent for Service of Process: (Must Be Located In California.) (See Corporations Code Sections 1505, 15800, 17057, 17060.) Name:_____________________________________________________________________________________________ Street Address:____________________________________________________________________________________ City and State:_________________________________________________________ Zip Code:_________________ 20. Disclosures a. Has the registrant, or any of the general partners, or corporate officers or directors, or limited liability company members, managers, and officers, ever been convicted of any felony? ❒ No ❒ Yes If yes, please explain on additional page. b. Within the last ten years, have any of these persons had any civil, criminal, or regulatory sanctions imposed against them pursuant to any state or federal consumer protection law or regulation? No Yes If yes, please explain on additional page. ❒ ❒ 21. Provide a full set of fingerprints of: (1) if a sole proprietorship, the registrant; (2) if a partnership, all general partners; (3) if a corporation, all corporate officers; and (4) if a limited liability company, all of the members, managers and officers. If your company does not offer electric service to residential or small commercial customers, this fingerprinting requirement may be limited to a designated corporate officer(s) approved by the Energy Division. Use the fingerprint cards included with this application. Additional fingerprint cards may be obtained from the Commission. The fingerprints shall be performed by a law enforcement agency, or other person which is qualified to provide fingerprint services. The ESP registrant shall also provide the name and address of the entity or person which provided the fingerprint services, and the date on which the service was provided. NOTICE Each ESP registered with the California Public Utilities Commission (CPUC) should be familiar with all the laws and decisions pertaining to the offering of electrical services to customers in California. This notice mentions some of the provisions that the ESP must abide by. To be issued an ESP Registration number, your you are required to provide the CPUC with a cash (cashier’s check) security deposit in the minimum amount of $25,000 or post a financial guarantee bond in favor of the CPUC in that amount. This deposit must be received by the CPUC before your ESP registration will be considered complete. The deposit or financial guarantee bond shall be delivered to the Energy Division address listed on the first page of this form. In the alternative, the ESP may elect to open a customer trust account in a format approved by the CPUC’s General Counsel. Pending such an approval, the ESP must post the cash deposit or the financial guarantee bond. This deposit requirement is subject to change. Unless you are an ESP who has been authorized by the California Independent System Operator to act as a scheduling coordinator, each registered ESP is required to submit to the Energy Division a copy of all of its scheduling coordinator agreements. The agreements are to be submitted on or before the date when the ESP signs up its first customer. Prior to signing up and initiating a direct access service request on behalf of any residential or small commercial customer, all registered ESPs serving such customers are required to provide the potential customer with a written notice which describes the price, terms, and conditions of service. The notice shall include all of the elements required by Public Utilities Code § 394.5, and the requirements set forth in the CPUC’s consumer protection decision, D.98-03-072, as modified by D.99-05-034. Public Utilities Code § 394.7 prohibits all ESPs from soliciting those residential and small commercial consumers whose names appear on the list that is maintained pursuant to that code section. Page 5 of 7 Rev. 8/03 In order to change the electricity provider of a residential or small commercial customer, all ESPs must follow the verification procedures set forth in Public Utilities Code § 366.5. Each registered ESP serving residential or small commercial customers is required to submit annual filings containing information regarding its standard service plans. This information is to be submitted on the form adopted by the CPUC. (Public Utilities Code § 392.1(a); D.98-03-072.) Each ESP who offers to sell electricity to end-use customers is required to disclose its electricity sources to those customers in accordance with Public Utilities Code § 398.4 and as directed by the California Energy Commission. In addition to the $100 registration fee, you are required to pay the annual fee required by Public Utilities Code § 394.3(b). This fee is assessed on each registered ESP on September 1st of each year. For the purposes of this form, the following definition of an “affiliate” applies: “Affiliate” means any legal entity in which five percent or more of the outstanding shares are owned, controlled, or held with power to vote, directly or indirectly either by the ESP or any of its subsidiaries; or by the ESP’s controlling entity or any of its subsidiaries; or by any company in which the ESP, its controlling entity, or any of the ESP’s affiliates, exert substantial control over the operation of the company or indirectly have substantial financial interests in the company which is exercised through means other than ownership. For purpose of this definition, “substantial control” include, but is not limited to, the possession, directly or indirectly and whether acting alone or in conjunction with others, of the authority to direct or cause the direction of the management or policies of the company. A direct or indirect voting interest of five percent or more by the ESP in an entity’s company creates a rebuttable presumption of control. Any material change in the information required by this form shall be provided to the CPUC within 60 days, except for any change in the ESP’s telephone number or address, which shall be reported within five days of such a change. (Public Utilities Code § 394.1(d).) Submit the original signed form together with all required documents, and three additional copies. Page 6 of 7 Rev. 8/03 DECLARATION If this registration form is verified outside of California, the verification must be made by an affidavit sworn or affirmed before a notary public.) I, (print name and title) ___________________________________________________________ hereby certify that I am empowered to act on behalf of _______________________________________________ (registrant’s name) and to make this application on its behalf. I declare under the penalty of perjury under the laws of the State of California that I have read the above notice, that the above statements and information submitted in connection with this application are true and correct, and that any documents furnished in connection with this application are true and correct copies. Dated this ___________________________________________, at _____________________________________________ (date) (place of execution) Signature:__________________________________________________________ (END OF ATTACHMENT A) Page 7 of 7 Rev. 8/03