TAXI Access Connectivity Request Form

* Required Information

Contact's First Name: *
Contact's Last Name: *
Contact's Phone Number: *	In the form XXX-XXX-XXXX
Provide six numeric digits and make a note for future use: *	In the form XXX-XXX
Contact's e-mail address: *
Supervisor's Name: *
Supervisor's Telephone Number: *	In the form XXX-XXX-XXXX
Company Name: *
Company Type: *	Access
Company Address: *
City: *
State: *
Zip Code: *
ACNA: *	(Access Customer Name Abbreviation) Note: ACNAs are three-character alpha codes assigned by Telcordia Technologies, Inc. Enter the industry-recognized ACNA(s) associated with the user's company. There may be one or more.
State: *	Note: The state where your company will do business.
Call back transactions: *	Yes No ( Web services adapters layer component will invoke Access Customer web services to send asynchronous SOAP message back to Access application.) Digital certificate and URL are required from the Access Customer.
Notifications:*	Yes No (Verizon will send Event and Closeout Notifications to the Access Customer dynamically) Digital certificate and URL are required from the Access Customer.
Contact's Signature: *	(Type your name here)
	By typing your full name in the above box you have signed this electronic document.
Comments:
Application Date:*	(MM/DD/YYYY)