Letter of Authorization
For Local Number Porting (LNP)
The undersigned hereby authorizes T5 Telecom to act on the Customer&rsrsquo;s behalf to port the numbers listed below. Current Provider: test provider Please fill out the following information as it appears on the Customer Service Record (CSR) of the current carrier: Customer Name test customer Service Address Service_address:
test address
Service City, State & Zip Code City:
test city
State: Zip Code:
, MI 49301
Please fill out the following information as it appears on the customer invoice with the current carrier: Billing Address test address Billing City, State & Zip Code test city/state/zip Additional Portability Information: Existing BTN (Billing Telephone Number):
(616) 555Existing BTN (Billing Telephone Number) with current carrier: 1212 Will you be porting this BTN? Is this a partial port? New_btn:
If yes, please indicate an new BTN for the current carrier:
Porting TNs (10-digit format, separate with commas or one-per-line, ranges are acceptable): Tns_to_port:
6165551212 test Authorized Printed Name: authuser Authorized Signature: test
user
Date_signed:
Date Signed (Must be dated within 30days to be valid):
Saturday, June 17, 2017
Electronic Signature Process Record The document above has been electronically signed in accordance with the law. YUID: 886de3bf-b21a-494e-9f0d-bdc9d8f09a3b-b7a5a473-7741-4abb-9c2e-693003cd8111 Signing party: Authorized User Signer ID: bef823a5-39e8-4d19-bdaf-84ada0517424 IP Address: 172.19.176.35 Timestamp: 2017-06-17 20:55:04 PDT (2017-06-18 03:55:04.560Z) Email:
[email protected] User: T5 Telecom Support
(9c6b1b42-af8c-4e6d-a54f-047a2427edb3)
