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.

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

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):

InitialChange

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

State Certification Information

State

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

Type

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/Firm

Phone Number

Email Address

Executable Document Contact Information:

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

YesNo

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?

YesNo

Name

Title/Firm

Phone Number

Email Address

Street Address

City

State

Zip

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

YesNo

Provisioning Contact Information

Name

Title/Firm

Phone Number

Email Address

Street Address

City

State

Zip

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

YesNo

Escalation Contact Information

Name

Title/Firm

Phone Number

Email Address

Street Address

City

State

Zip

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

YesNo

Maintenance/Repair Contact Information

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?

CheckElectronic Funds Transfer

Bank Name

Bank Street Address

Bank City

Bank State

Bank Zip

Bank Phone Number

Bank Fax Number

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

YesNo

Tax Matters Contact Information:

Name

Title

Phone Number

Email Address

Street Address

City

State

Zip

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

YesNo

Usage Data Contact Information:

Name

Title

Phone Number

Email Address

Street Address

City

State

Zip

Default Country Code

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.