E-sign LNP Authorization Form

The undersigned does hereby appoint VoIP Route as the Responsible Organization for the number(s) listed below. VoIP Route may order new service, change exisiting service & request carrier information. This authorization shall remain in effect until further written notice is provided.

Current Phone Service Provider Company Name*

Obtained from phone bill

Current Service Provider BTN*

Obtained from phone bill

Current Service Provider Account #*

Obtained from phone bill or use BTN

Billing Account Holder Name*

Obtained from phone bill

Authorized Account Holder Name*

Authorized user name

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Service Address is different than billing address?*

YesNo

Service Address

Street Address

Street Address Line 2

CityState

Zip Code

Contact Number(s)*

Please enter a number(s) we may reach you for questions

Contact Name*

Please enter name of person we will speak with

E-mail for notifications*

Used for status updates and never shared

Main number to be ported & associated with Caller-ID, e411 & e911 (must be associated with the BTN listed above) WHEN ONLY PORTING FAX NUMBERS ENTER 000-000-0000*

Enter your main number

Name for Caller-ID*

15 character limit for Caller-ID

Are you porting additional Non-Fax number(s)?*

YesNo

Additional number(s) to be ported (must be associated with the BTN listed above)

	Number	Number	Number	Number	Number	Number
Porting
Porting
Porting
Porting

Are you porting a Fax number(s)?

YesNo

Fax number(s) to be ported (must be associated with the BTN listed above)

	Number	Number	Number	Number	Number	Number
Porting
Porting
Porting
Porting

Complete or Partial port*

Complete - ports ALL existing numbers from your current providerPartial - leaves some numbers with your current provider & account *typically used when only porting fax number(s)*

Notes:

Additional Helpful Info

By submitting this request I certify the above information is accurate and authorize VoIP Route to port my number(s). I also understand that any charges incurred to port number(s) are my responsibility and not VoIP Route's.*

In order to process this request you must submit a current bill with the BTN clearly visible.*

Signatory Name (printed):*

Printed full name of authorized signer

Signatory Title:*

Authorized signers work title or position

Date*

MonthDayYear

Electronic Signature (legally binding). Your IP address is associated with your authorization.*

Please use your mouse or stylus to create a signature above

For questions, please contact support@myvoiproute.com or call 305-602-3780

Validation*

Please attach your most recent bill*

Upload a File

Attach scanned copy of recent phone bill

LNP Letter of Authorization