Section 1 CLEC Information

PON*	Pre	cC*	PG	OF

(Note: “PRE” is part of the PON and indicates a pre-order request. Do NOT include the “PRE” in the PON field of the LSR when submitting the firm order request)

Today’s date	clec NAME

contact person

contact tn

eMAIL

Section 2 End User Address Information (Required)

NAME

SAPR	SANO	SASF	SASD

SASN

SATH	SASS	LD1	LV1

LD2	LV2	LD3	LV3

AAI

CITY

STATE	ZIP CODE

Route	Box	Previous Owner Name

CLEC Information

PON*	Pre	cC*	PG	OF
(Note: “PRE” is part of the PON and indicates a pre-order request. Do NOT include the “PRE” in the PON field of the LSR when submitting the firm order request)

Section 2a End User Address – Unable to Validate Address (Optional)

New Construction – Address is new construction; possibly within a new subdivision, housing tract, etc

Not New construction – Address was not returned by the system.

however, end user has verified that address is correct

cross streets

subdivision name, TRACK #, lot #

additional information

working telephone number, if available

Section 2b End User Address Request Validation (Optional SBC Southwest Only)

Yes - Request Address Validation

CLEC Information

PON*	Pre	cC*	PG	OF
(Note: “PRE” is part of the PON and indicates a pre-order request. Do NOT include the “PRE” in the PON field of the LSR when submitting the firm order request)

Section 3: Telephone Number & Service Information – Optional (Populate this section when requesting Telephone Number Reservation)

Number of Telephone NumberS requested

Sequential Numbers - Yes

POTS BUSINESS

POTS RESIDENCE

COIN (PAYPHONE)

BUSINESS METRO SERVICE (at&t sOUTHWEST ONLY)

rESIDENCE METRO SERVICE (at&t sOUTHWEST ONLY)

FOREIGN EXCHANGE/RCF	nUMBER OF LINES REQUESTED

REQNUM

Hunt Group Information (HGI) Request Information

Multi-line hunting - Yes	HuNT tYPe

number of Hunt groups

TN Cancel

TELEPHONE NUMBER

TELEPHONE NUMBER RESID

Effective - 09/06/11 067119

Address Validation/TN Reservation Form

Effective - 09/06/11 067218

Effective - 09/06/11 067317

Local Hunting Service Request

RB0055526

2010-10-01

William Burkhalter

SBC