INTERCONECTION AGREEMENT
INFORMATION REQUEST FORM
TO BE COMPLETED FOR EACH INTERCONNECTION AGREEMENT REQUESTED
Please return to: Windstream Communications, Inc.
Wholesale Services
4001 Rodney Parham Road
1170 B1F2-12A
Little Rock, AR 72212
Facsimile: (501) 748-6583
The following information must be provided and certified by a duly authorized officer or attorney of the business entity(ies) which will be named as the executing party(ies) in the Interconnection Agreement (collectively the "Contracting Party".
Please check one of the following:
CLEC RESALE CMRS
ONLY
Please provide the following CONTRACTING PARTY information:
- Operating Company Number (OCN):
- Access Customer Name Abbreviation (ACNA):
- Tax ID:
- List the Exchange(s) of intended service and operation:
- Cable Companies: Please list the Cable Franchise territories and provide franchise
certification(s) within the State interconnection is requested:
Please check the individual state of intended service and operation:
ALABAMA ARKANSASFLORIDAGEORGIA
KENTUCKYMISSISSIPPI MISSOURINEBRASKA
NEW MEXICONEW YORKNORTH CAROLINAOHIO
OKLAHOMAPENNSYLVANIATEXASSOUTH CAROLINA
- The exact legal name(s) of the CONTRACTING PARTY which will be legally bound by the Interconnection Agreement.
d/b/a
- The business title and individual name of a duly authorized Officer of the CONTRACTING PARTY with execution authority to bind the CONTRACTING PARTY:
Name:
Title:
- The street address(es), telephone and facsimile numbers of CONTRACTING PARTY's principal place(s) of business:
Address:
Telephone:Facsimile:
Email Address:
- The state in which the CONTRACTING PARTY is incorporated:
- The name, street address, telephone number, facsimile number, and email address of the Registered Agent, or other person, authorized to receive legal notice for the CONTRACTING PARTY:
Name:
Address:
Phone Number:
Facsimile:
Email Address:
6.The name, street address, telephone number, facsimile number, and email address of the person authorized to receive Notices pertaining to the terms of the Interconnection Agreement.
Name:
Address:
Phone Number:
Facsimile:
Email Address:
7.The name, street address, telephone number, facsimile number, and email address of the person authorized to receive notices regarding Taxes:
Name:
Address:
Phone Number:
Facsimile:
Email Address:
8.Please provide a 24-hour contact and facsimile number for Network Traffic Management issues.
Phone Number:
Facsimile:
- ICA Details – Services Contracting Party requests Windstream to provide:
Please provide a description of the type(s) of services Contracting Party is requesting to be included in the interconnection agreement, i.e. types of collocation, unbundled network elements, transport and termination of traffic. Please detail so Windstream can tailor the ICA to suit Contracting Party’s needs.
- Contracting Party – Copy of Tariff & Detail of Services Contracting Party will offer in Windstream service area:
Please provide a description of the type(s) of service and a copy of Tariff Services Contracting Party will be offering in the intended Windstream service area.
- The following documents must be provided before agreement will be prepared for execution:
(a)Please provide copies of the Articles of Incorporation for the state in which the CONTRACTING PARTY is incorporated; and
(b)(1) A copy of the Certificate of Authority or Certificate of Public Convenience and Necessity that was granted by the Public Service Commission in the state in which you requesting this agreement; and
(2) A copy of the Contracting Party Tariff Services.
(3) A copy of the Contracting Party Cable Franchise territory state certification (s).
(c)A copy of the FCC PCS License that was granted by the FCC for the Windstream area you intend to interconnect.
- Please provide all supporting documentation if Contracting Party is planning to claim any tax exemptions.
I , as / or attorney for
(NAME)(OFFICER'S TITLE)
, the CONTRACTING PARTY, do hereby certify that the foregoing
(COMPANY)
information is correct.
Signature:
Telephone:
Date:
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