DEDICATED SERVICE AGREEMENT - NON TEXAS Page 1

For Customer Service Call: 1-888-286-2685 DSA 600

Revised 1.17.2003

ACC BUSINESS REPRESENTATION

Agent / Retention Manager: / CHANNEL ID # / Telephone Number
Agent Name:
SubAgent Name:

ACCOUNT INFORMATION (Please provide a separate Service Agreement and Technical Form for each Service Location)

Please note that the fields in sections I, II, and III are required

COMPANY INFORMATION / BILLING INFORMATION (if different than company information)
I. Company Name (Service Company Name) / II. Bill To:
Company Address / Street
City / State / Zip Code / City / State / Zip Code
Contact Person / Phone Number / Billing Contact Person / Billing Contact Phone Number
Contact Fax Number / Contact Email Address / III. REQUIRED FOR ALL: Legal Company Name (Parent Company)
(Billing Email Address)

ACCOUNT DETAIL INFORMATION

Average Monthly Usage / Monthly Revenue Commitment (MUC) / New Account / Tax Exemption (send certificate)
Existing Account Account # / Federal: / State:
Does this Agreement accompany a new Switched order? Yes No / 4-Digit Non-Verified Account Code? Yes No
Migrating service from AT&T or AT&T reseller? Yes No / *If yes, existing AT&T service is Dedicated (and/or) Switched

BILLING OPTIONS (refer to Billing Options document, found on A.I.M)

STANDARD BILLING (Single Account Billing)
MULTI-ACCOUNT BILLING (Please provide separate Service Agreements for Each Account)
Multi-Account Service Option: 1 2 Headquarters Account Name (Company):
CORPORATE BILLING: $6.50/mo. Administrative Fee plus $3.00/mo. each service location
Corporate Billing Option: 1 2 3 4
Corporate Billing: Is the above Service address the Headquarters Location? (Y/N): YN / Corporate Billing: Location # of
Billing Report Options (please provide supporting paperwork): / Access-a-Bill / a la carte Tele-management Reports

SERVICE TERM AND PROMOTIONS

/ Term Plans (Domestic) / 12 Mo. / 24 Mo. / Tier:
Promo Code(s):

SERVICE CHARGES & RATE PLANS

Access Type: (Unit) / T1.5 / -OR- / T-3 / # of Units:
(T-1s or T-3s) / Service Type: / Total / -OR- /
Baseline
Monthly Access Charges (per Unit) / Rates /
Dedicated
Usage / Interstate: /
International Plans
Gross Monthly Discount (per Unit) / InterLATA: / Standard
Net Monthly Access Charge (per Unit) / IntraLATA: / Economy

TOTAL Net Monthly Charge for Access

(qty Units x net monthly Unit charge)

/ Dedicated Local service on T1?Yes (include page 3) No
If ISDN/PRI, TOTAL monthly charge for D channel(s):
(qty of D channels required x $185.00=) / Deliver ANI with toll free service (caller ID / ISDN or Inband-ANI)?
Yes: if yes $0.01 per completed toll free call No
Special Charges & Pricing:

DEDICATED SERVICE REQUEST SUMMARY (Please complete the Technical Specifications Form with Service Details)

DEDICATED LONG DISTANCE

DEDICATED TOLL FREE / Quantity of New 8YY # s / Quantity of RespOrg #’s

DEDICATED LOCAL

CREDIT INFORMATION

NOTE: Credit Application and most recent Bill Copy Summary Page must be Attached for New Customers
Credit Pre-Approved? / Pre-Approved by (ACC Business Credit Rep): / Pre-Approval Date:

SIGNATURE BELOW BY YOUR AUTHORIZED REPRESENTATIVE IS YOUR CONSENT TO THE

TERMS AND CONDITIONS OF THIS AGREEMENT

The Customer acknowledges the attached ACC Business Term Plan Terms and Conditions apply to the Customer’s term plan services that have been detariffed, and the applicable AT&T tariffs apply to the Customer’s term plan services that remain tariffed. As the Customer’s tariffed term plan services are detariffed, they will also be covered by the attached ACC Business Term Plan Terms and Conditions. Following expiration of the term or other termination of the Customer’s term plan agreement, if the Customer continues to receive any term plan services and does not enter into a new term plan agreement, the terms and conditions set forth in ACC Business’ standard Business Communications Services Agreement found at shall apply to Customer’s services. Additional terms, conditions and charges can be viewed at
Customer authorizes ACC Business to request a credit report from a credit-reporting agency in connection with this agreement. Customer understands that upon request ACC Business will advise if a credit report was requested and provide the name and address of the credit agency furnishing the credit report.
Customer / ACC Business
Name (Printed) / Name (Printed)
Signature (x) / Signature (x)
Company Name / Title

Agent / Retention Manager

Title / Date
Date

DEDICATED LOCAL SERVICE AND CHARGES

Dedicated Local included with new T1 order? Yes No / Add Dedicated Local to existing ACC Business T1? Yes No
Customer’s Type of Business / # of Employees at Service Address
Expected Local Monthly Usage of Minutes (Estimated)
Direct Outward Dial (DOD): Direct Inward Dial (DID): Originating Toll Free:

DIRECT OUTWARD DIAL (DOD) LOCAL SERVICE CHARGES

DOD Service? Yes No / Measured Rate for local calling area:
Note: DOD required if DID service is ordered on T1
/ TOTAL Flat Rate for ACC Business local calling area:
(Flat Rate x qty of T1's=)

DIRECT INWARD DIAL (DID) LOCAL SERVICE CHARGES

DID Service? Yes No / TOTAL Monthly DID Facility Charge:
(Monthly DID Facility charge x qty of T1's=)
Quantity of New Numbers assigned by ACC Business: / Quantity of
Numbers to port: / Monthly Charge for DID phone #s:
MAIN LISTED NUMBER (MLN – Directory) CHARGES
List Main Number on ACC Business T1 with DID Service?
YesNo / Monthly Charge for MLN Service (if applicable):
Additional Listing? Yes No / Non-Recurring Charge for MLN Service:
ADDITIONAL CHARGES
Special Charges & Pricing: / TOTAL Multi-Line End User Carrier Line (EUCL) charge:
(EUCL x qty of T1's= )
AGREEMENT – ADDITIONAL TERMS FOR DEDICATED LOCAL
Customer is aware that they are required to keep individual business lines or other appropriate facilities with the LEC in order to provide 911 service and certain other services and/or codes. Customer acknowledges that ACC Business is not responsible for any expenses related to equipment upgrades and/or installation at their service location that may be required to successfully turn up dedicated local service.

ACCEPTANCE

Customer / ACC Business
Name (Printed) / Name (Printed)
Signature (x) / Signature (x)
Company Name / Title

Agent Manager

Title / Date
Date