Telephone Number Porting Authorization Form
Complete the LOA details and provide the required porting information for the phone numbers you’re transferring.
Authorization Information
Provided LOA Code #
I acknowledge and certify that I am an authorized representative of the company and have authority to request this telephone number porting action.
*
I acknowledge and certify this statement
First Name
Last Name
Company Name
*
Additional Porting Information
Account Number
PIN or last 4 digits of SSN
Billing Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Help Text
Phone Number 1
Phone Number 2
Phone Number 3
Phone Number 4
Phone Number 5
Phone Number 6
Phone Number 7
Phone Number 8
Phone Number 9
Phone Number 10
Phone Number 11
Phone Number 12
Phone Number 13
Phone Number 14
Phone Number 15
Phone Number 16
Phone Number 17
Phone Number 18
Phone Number 19
Phone Number 20
New BTN
*
Customer Information and Signature
Authorized Name
*
First Name
Last Name
Title
Email Address
example@example.com
Company Name
*
Street Address
*
Street Address Line 2
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
Zip Code
*
Authorized Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Recv'd Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: