TAXI Local 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: *	CLEC Reseller
Company Address: *
City: *
State: *
Zip Code: *
ECC: *	(Exchange Carrier Code) Note: Exchange Carrier Code Assigned by Telcordia (4 or 2 digit alpha code)
Default State: *	Note: The state where your company will do business in
Call back transactions: *	Yes No ( Web services adapters layer component will invoke CLEC web services to send asynchronous SOAP message back to CLEC application.) Digital certificate and URL are required from the CLEC.
Notifications:*	Yes No (Verizon will send Event and Closeout Notifications to the CLEC dynamically) Digital certificate and URL are required from the CLEC
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)