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”).
Form Submitted by:
Name (Full Name)
Title
Company Name
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
ACNA (Access Carrier Name Abbreviation)
ACNA (aka IAC Code) is a three-character alphabetic code.
Separate multiple entries with a comma.
Entity Legal Form
Corporation Limited Liability Company Limited Partnership or Other
State Legal Form Established
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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: Wholesale.Tax.Exemption@ftr.com.
Type of Agreement (Form Submission Type):
Initial
Change
Change Description
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]
Check All that Apply
Select the State(s) this request pertains to:
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 Certification 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 Carbon Copy to:
Street Address
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?
Yes
No
Name
Title/Firm
Phone Number
Email Address
Street Address
City
State
Zip
Ordering Contact information
Name
Title/Firm
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?
Yes
No
Name
Title/Firm
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?
Yes
No
Name
Title/Firm
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?
Yes
No
Name
Title/Firm
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?
Yes
No
Name
Title/Firm
Phone Number
Email Address
Street Address
City
State
Zip
Billing Contact Information:
Name
Title/Firm
Phone Number
Email Address
Street Address
City
State
Zip
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?
Check
Electronic Funds Transfer
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?
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?
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.