Requester Information (To be completed by CLEC)

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

clec assigned reference number

contact person	contact tn

Administrative Section

an

End User Information (Required for xDSL)

NAME

SAPR	SANO	SASF	SASD

SASN

SATH	SASS	LD1	LV1

LD2	LV2	LD3	LV3

AAI

CITY

STATE	ZIP CODE

End User’s Working Telephone Number

Request for Manual Loop Qualification

I authorized AT&T to issue a Manual Loop Request (MLR), only when needed (no actual/archived data is available)

I authorized AT&T to issue a Manual Loop Request (MLR), even when actual/archived data is available.

Effective - 11/13/10 068116

Loop Qualification Request Form For Preorder Use Only

(DSL/Line Sharing/Broadband – REQTYP A Only)

Local Hunting Service Request

RB0055526

2010-10-01

William Burkhalter

SBC