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Interconnected VoIP Request Form

Interconnected VoIP Request Form

Form Submission Date

Information provided on this form must be certified as correct by a duly authorized Officer, Consultant or Attorney of the business entity that will be named as the execution party in the Agreement (the “Contracting Party”).

*Denotes Required Field

Form Submitted by:

Name* (Full Name)

Phone Number*

Email Address*

By submitting this form, I as the requestor for the Contracting Party, do hereby certify that the foregoing information is correct.

Contracting Party

Legal Entity Name*

Legal Entity Name above represents the contracting party to be legally bound by submission of this form. Include d/b/a if appropriate.

Affiliate Company Name(s)*

(Enter 'None' if no affiliates.)

Preferred Company Acronym or Abbreviated Name

Entity Legal Form*

Corporation Limited Liability Company Limited Partnership or Other

State Legal Form Established*

State Legal Form Established

Federal Tax ID Number*

If the new account numbers are to be coded “exempt” from any applicable taxes and surcharges, certificate of exemption from the Federal Excise Tax and all other appropriate forms indicating exemption from state/local taxes must be provided.

All Tax Exemption Forms and any additional tax exemption information must be submitted via email to: [email protected].

Type of Agreement

Form Submission Type:

Form Submission Type Initial Change (Provide change description below)

Please type the change details here

Product Options * (Please check all that apply.)

Product Options* LNP Only (No Directory Listings) [CB] LNP w/Directory Listings (Requires an Agreement) [CB, JB] Expedited LNP Request (Requires an Agreement) [CB] - Interval that is less than FCC mandated interval. Stand Alone Directory Listing Only (No LNP - Requires an Agreement) [JB]

Select the State(s) this request pertains to*

If selecting 'All Frontier States' checkbox below, please be patient while states load to form....

All Frontier States States AL AZ CA CT FL GA IA IL IN MI MN MS NC NE NM NV NY OH PA SC TN TX UT WI WV

State Information

AL - Alabama

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

AZ - Arizona

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

CA - California

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

CT - Connecticut

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

FL - Florida

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

GA - Georgia

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

IA - Iowa

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

IL - Illinois

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

IN - Indiana

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

MI - Michigan

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

MN - Minnesota

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

MS - Mississippi

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

NC - North Carolina

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

NE - Nebraska

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

NM - New Mexico

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

NV - Nevada

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

NY - New York

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

OH - Ohio

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

PA - Pennsylvania

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

SC - South Carolina

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

TN - Tennessee

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

TX - Texas

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

UT - Utah

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

WI - Wisconsin

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

WV - West Virginia

ACNA/CCNA*

OCN*

SPID*

State Tax ID Number*

LATA(s)*

List each LATA where your company will be porting numbers (LNP).

3rd Party Network Provider*

Network Provider Contact Name*

Network Provider Contact Email*

Legal Notice Contact Information:

Note: Designee should be a Contracting Party Employee

Name*

Title/Firm*

Phone Number*

Email Address*

Email Copy to:

Email Copy to:

Street Address*

Physical Address Required - P.O. Box Unacceptable

City*

State*

Zip*

Contracting Party's Duly Authorized Officer with Execution Authority to Bind the Contracting Party:

Name*

Title*

Phone Number*

Email Address*

Executable Document Contact Information:

Is the Executable Document Contact Information the same as Legal Notice Contact Information provided above?

Executable Document Address Same as Above Yes No

Name*

Title/Firm*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Ordering Contact Information

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Street Address Guide (SAG)/911 Contact Information

Is the Street Address Guide (SAG)/911 Contact Information the same as Ordering Contact Information provided above?

SAG Same as Above Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Provisioning Contact Information

Is the Provisioning Contact Information the same as Ordering Contact Information provided above?

Provisioning Info Same as Ordering Info Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Escalation Contact Information

Is the Escalation Contact Information the same as Ordering Contact Information provided above?

Escalation Info Same as Ordering Info Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Maintenance/Repair Contact Information

Is the Maintenance/Repair Contact Information the same as Ordering Contact Information provided above?

Repair Info Same as Ordering Info Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Billing Contact Information:

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Bill Media Options

Bill Media Options Frontier Self-Service Tools (CABS Bill Portal, COBRA Portal) BDT (Electronic Billing Feed)

Selecting BDT as a Bill Media Option requires a Billing Feed Connectivity Form submission.

Please access form at: https://wholesale.frontier.com/Forms/Billing-Feed-Connectivity-Form

Information about Frontier Billing Statement Tools is available online at: https://wholesale.frontier.com/billing/Online-Billing-Statement-Tools

Payment Information

How will your company make payments to Frontier?

Payment Type Check Electronic Funds Transfer

Please visit https://wholesale.frontier.com/billing/payment-remittance for payment information.

Bank Name*

Bank Street Address*

Bank City*

Bank State*

Bank Zip*

Bank Phone Number*

Bank Fax Number*

Tax Matters Contact Information:

Is the Tax Matters Contact Information the same as Billing Contact Information provided above?

Tax Matters Address Same as Above Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

Usage Data Contact Information:

Is the Usage Data Contact Information the same as Billing Contact Information provided above?

Usage Data Contact and Address Same as Above Yes No

Name*

Title*

Phone Number*

Email Address*

Street Address*

City*

State*

Zip*

As the submitter, acting on behalf of the Contracting Party, I do hereby certify that the information provided on this form is correct. I understand that by submitting this form I am providing my electronic signature.

To ensure receipt of confirmation, please accept emails the following sender address: [email protected]

PROPRIETARY NOTICE
THE MATERIAL CONTAINED IN THIS WEBSITE AND THE AVAILABLE REFERENCE DOCUMENTS INCLUDING ANY TRANSLATIONS, COMPILATIONS, WHOLE OR PARTIAL COPIES, TOGETHER WITH ANY SUBSEQUENT REVISIONS OR ADDITIONS ARE AND SHALL REMAIN THE PROPERTY OF FRONTIER COMMUNICATIONS PARENT, INC. AND ITS AFFILIATES. NO PORTION OF THESE MATERIALS MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM BY ANY MEANS, ELECTRONIC, MECHANICAL OR OTHERWISE, INCLUDING PHOTOCOPY, RECORDING OR ANY INFORMATION STORAGE OR RETRIEVAL SYSTEM WITHOUT ADVANCE WRITTEN PERMISSION FROM FRONTIER. SHOULD THE HOLDER OF THESE MATERIALS HAVE SUCH WRITTEN PERMISSION TO MAKE COPIES OF THESE MATERIALS, ALL SUCH COPIES MUST CONTAIN THIS PROPRIETARY NOTICE. FRONTIER IS A BRAND NAME USED BY THE FRONTIER, CITIZENS AND OTHER AFFILIATED LOCAL EXCHANGE COMPANIES. ALL RIGHTS RESERVED.

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