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 Type

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

Type of Agreement

InterconnectionResaleTraffic ExchangeOther

If Other, provide explanation:

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

ACNA (aka IAC Code) is a three-character alphabetic code.
Separate multiple entries with a comma.

Type of Carrier

Competitive Local Exchange Carrier (CLEC)Commercial Mobile Radio Service Provider (CMRS)

Entity Legal Form

Corporation Limited Liability Company Limited Partnership or Other

State Legal Form Established

Is CLEC Facilities-Based or Reseller?

Contracting Party’s Legal Notice Contact:

Name	Title/Firm
Phone Number	Email Address
Carbon Copy Email 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/Firm

Email Address

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?

YesNo

Name	Title/Firm
Email Address	Phone Number
Street Address	City
State	Zip

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?

YesNo

Name	Title/Firm
Email Address	Phone Number
Street Address	City
State	Zip

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?

YesNo

Name	Title/Firm
Email Address	Phone Number
Street Address	City
State	Zip

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?

YesNo

Name	Title/Firm
Email Address	Phone Number
Street Address	City
State	Zip

State Certification Information

State Code

What is your Certification status for this state?

ApprovedPending

Certification Number(s)

Certification Date*

Date Certification Filed*

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

YesNo

Exact Legal Entity Name as Filed with the State Commission

Legal Form of Entity

Corporation, Limited Liability Company, Limited Partnership, or Other

State Legal Form Established

Type

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.