LNP Request Form All of the information provided on this port request must match the data on your bill/CSR with your current provider. Failure to provide matching data will result in order rejection. This process, without rejections may take 3-6 weeks for completion. PLEASE NOTE: If the following information requested does not match what the loosing carrier has on record for the end user, the order will likely be rejected. Please verify all information with the loosing carrier prior to submitting your order. Disconnected numbers cannot be ported; The number(s) must be active. Rejected ports will still incur a port fee. Numbers to Port*Click the (+) to add a new line. Partial Port*Are all numbers on account being ported?Yes, port all numbers on the account.No, port ONLY the numbers listed above.Are these Numbers for "Wireless" Service?*YesNoInformation Required By Wireless ProvidersWireless/Cellular telephone carriers require the following additional pieces of information. Without this information, the Service Provider may, and usually will, deny any porting of telephone numbers.Last 4 of SS#Account PINService Provider Name*Account Number*Name on Statement*Authorized Contact* First Last Contact Title*EmployeePresident/CEOOwnerService Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Telephone Number*Authorization to Port* I authorize the numbers listed above to be ported, and agree to the terms. Authorized Signature*Please sign completely in the box. Do not cross over the lines This iframe contains the logic required to handle Ajax powered Gravity Forms.