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251-252 Interconnection Information Request Form

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:

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

Type of Agreement*

Contracting Party

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

(Enter 'None' if no affiliates.)

Type of Carrier*

Corporation Limited Liability Company Limited Partnership or Other

State Legal Form Established*

Is CLEC Facilities-Based or Reseller?

Contracting Party’s Legal Notice Contact:

Physical Address Required - P.O. Box Unacceptable

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

Contracting Party's Representative Authorized to Receive the Executable Document:

Is the Executable Document contact and address the same as Contracting Party’s Legal Notice Contact provided above?

Contracting Party's Individual/Department to Receive Legal Notice Regarding Tax Matters:

Is the Tax Matters contact and address the same as Contracting Party’s Legal Notice Contact provided above?

Contracting Party's Authorized Individual/Department to Receive Usage Data:

Is the Usage Data contact and address the same as Contracting Party’s Legal Notice Contact provided above?

Contracting Party's Individual/Department to Receive Legal Notice Regarding Charges & Payments (Billing):

Is the Charges & Payments contact and address the same as Contracting Party’s Legal Notice Contact provided above?

Select the State(s) this request pertains to*

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

State Certification Information*

AL - Alabama

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

AZ - Arizona

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

CA - California

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

CT - Connecticut

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

FL - Florida

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

GA - Georgia

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

IA - Iowa

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

IL - Illinois

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

IN - Indiana

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

MI - Michigan

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

MN - Minnesota

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

MS - Mississippi

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

NC - North Carolina

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

NE - Nebraska

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

NM - New Mexico

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

NV - Nevada

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

NY - New York

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

OH - Ohio

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

PA - Pennsylvania

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

SC - South Carolina

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

TN - Tennessee

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

TX - Texas

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

UT - Utah

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

WI - Wisconsin

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

WV - West Virginia

What is your Certification status for this state?

Are you (or will you be) certified under the same Legal Entity Name provided above?

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established*

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]

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