Letter Of Authorization Form-Voip Service
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1LETTER OF AUTHORIZATION –VOIP SERVICE
1. Customer Name
(Your name should appear EXACTLY as it does on your local telephone bill.)
_________________________________________________________________________________________
First Name
Last Name
_________________________________________________________________________________________
Business Name
(Required only if phone service is in your Company’s Name.)
2. Service Address
(Primary address where the telephone service is currently located. No Post Office Boxes)
_________________________________________________________________________________________
Address
City
State
Zip/Code
3. Billing Address
(If different from above, should appear EXACTLY as it does on your local telephone bill.)
_________________________________________________________________________________________
Address
City
State
Zip/Code
.
4
List below only the Telephone Number(s) for which you authorize a change from your current phone service provider to
OnlineNW. Please note that your Local, In-state Toll and/or Long Distance service for the number(s) listed below will be
changed to OnlineNW, and that any services associated with this number(s), such as Centrex, DSL or Ringmate, will be
lost if you port this number(s).
Telephone Number(s) (list only numbers to be ported)
Current Service Provider
______________________________________________________
____________________________
______________________________________________________
____________________________
______________________________________________________
____________________________
______________________________________________________
____________________________
*
Billing Telephone Number “BTN” or Account Number
This MUST be provided even if the BTN number is not being ported
________________________________________
*Account Password
Only applies if you have specifically set up an account password for managing your phone service.
______________________
VERIFICATION - PLEASE READ BEFORE SIGNING BELOW
By signing below, I verify that I am, or authorized to represent (for a business), the above-named local service customer, authorized to
change the primary carrier(s) for the telephone number(s) listed, and am at least 18 years of age. The name and address I have provided is
the name and address on record with my local telephone company for each telephone number listed. I warrant that the address that I have
provided above is the address where I will be using this service. I authorize and designate OnlineNW to act as my agent and notify my
current carrier(s) to change my preferred carrier(s) for the listed number(s) and service(s), to obtain any information OnlineNW deems
necessary to make the carrier change(s), including, for example, an inventory of telephone lines billed to the telephone number(s), carrier
or customer identifying information, billing addresses, and my credit history. I further understand that after this process is completed
OnlineNW will become my Local, In-State Toll and Long Distance provider, as indicated above.
I understand that I am authorizing change(s) of my primary carriers for these Service(s), and that I may select only one primary carrier
per service, per number. I understand that my local telephone company may bill me a one-time charge for requested service change(s) for
each telephone number.
Signature: ____________________________________________________
Date: ___________________
Printed Name: ____________________________________________________________________________
For Office Use Below:
Ordered:
Port FOC:
Ipifony Prov:
ATA or DSLAM
Billing:
Other:
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Parent category: Letters