New TN Assignment – LOA Generator Directions: For use when needing to supply a LOA for a brand new 687 assignment. Letter of AuthorizationYour information should appear EXACTLY as it does on your most recent telephone bill. You will need to fill out one of these forms for each Current Provider accounts you want numbers to be provided from. Account Type(Required) Business Residential Business Name (as it appears on your current billing)(Required) Authorized Contact Name(Required) First Last Billing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Service Address (used for E911 - No PO Boxes)(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Proof of AuthorityWe will need a copy of your most recent invoice from your current phone provider. Use your phone bill to answer the following questions.Current Provider Name(Required) Current Provider Account Number(Required) Current Provider Billing Telephone Number (BTN)(Required) BTN Information(Required) BTN is being ported BTN is not being ported Port Request DetailsLocal Phone Number(s)List below only the Local Telephone Number(s) for which you authorize a change from your current phone service provider to OnlineNW/XS Media. Please note that your Local, In-state Toll and/or Long Distance service for the number(s) listed below will be changed as well, and that any services associated with this number(s), such as Centrex, DSL or Ringmate, will be lost if you port this number(s). Total of LOCAL numbers being ported(Required)Please enter a number from 1 to 999.Local numbers being ported(Required)Telephone Number/Range(s)Line use description Add RemoveClick the "+" to the left to add another line or range set. Line Description examples: Main Line, Standard Fax Line (physical fax machine), User Direct Dial Extension, Hunt Group, etc..VERIFICATION - PLEASE READ BEFORE SIGNING BELOWBy signing below, I verify that I am, or authorized to represent (for a business), the above-named local service customer, authorized to change the primary carrier(s) for the telephone number(s) listed, and am at least 18 years of age. The name and address I have provided is the name and address on record with my local telephone company for each telephone number listed. I warrant that the address that I have provided above is the address where I will be using this service. I authorize and designate OnlineNW/XS Media to act as my agent and notify my current carrier(s) to change my preferred carrier(s) for the listed number(s) and service(s), to obtain any information OnlineNW/XS Media deems necessary to make the carrier change(s), including, for example, an inventory of telephone lines billed to the telephone number(s), carrier or customer identifying information, billing addresses, and my credit history. I further understand that after this process is completed OnlineNW/XS Media will become my Local, In-State Toll and Long Distance provider, as indicated above. I understand that I am authorizing change(s) of my primary carriers for these Service(s), and that I may select only one primary carrier per service, per number. I understand that my local telephone company may bill me a one-time charge for requested service change(s) for each telephone number. Agreement(Required) I understand and confirm the above information is true. SignaturePrinted Name:(Required) First & Last Name Date(Required) MM slash DD slash YYYY Job Title Email(Required)