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Interconnected VoIP 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.

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.)

ACNA (aka IAC Code) is a three-character alphabetic code.

Separate multiple entries with a comma.

Corporation Limited Liability Company Limited Partnership or Other

State Legal Form Established*

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:

Product Options * (Please check all that apply.)

Select the State(s) this request pertains to*

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

State Information

AL - Alabama

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

AZ - Arizona

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

CA - California

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

CT - Connecticut

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

FL - Florida

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

GA - Georgia

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

IA - Iowa

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

IL - Illinois

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

IN - Indiana

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

MI - Michigan

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

MN - Minnesota

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

MS - Mississippi

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

NC - North Carolina

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

NE - Nebraska

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

NM - New Mexico

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

NV - Nevada

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

NY - New York

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

OH - Ohio

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

PA - Pennsylvania

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

SC - South Carolina

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

TN - Tennessee

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

TX - Texas

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

UT - Utah

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

WI - Wisconsin

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

WV - West Virginia

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

Legal Notice Contact Information:

Note: Designee should be a Contracting Party Employee

Physical Address Required - P.O. Box Unacceptable

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

Executable Document Contact Information:

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

Ordering Contact Information

Street Address Guide (SAG)/911 Contact Information

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

Provisioning Contact Information

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

Escalation Contact Information

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

Maintenance/Repair Contact Information

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

Billing Contact Information:

Bill Media Options

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?

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

Tax Matters Contact Information:

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

Usage Data Contact Information:

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

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]