Today's Date *

MM

DD

YYYY

Customer Name *

First Name

Last Name

Contact Phone Number *

This will be the best contact number for Smartaira to reach you at - not the number we are porting over for you.

(###)

###

####

Service Address listed on current provider's invoice *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing & Working Telephone Number(s) (BTN/WTN) numbers to be ported *

Please include all numbers to be ported below and specify if they are a phone or fax line.

(###)

###

####

(2ND) Billing & Working Telephone Numbers(s) (BTN/WTN) numbers to be ported*

Please include all numbers to be ported below and specify if they are a phone or fax line.

(###)

###

####

Requested Port Date* (optional)

If requesting a specific date of port please enter below A minimum of 10 days from date of this request is required for a requested date *Smartaira is not in control of the date of porting but will attempt to work with current provider(s)

MM

DD

YYYY

Revocation of Previous LOAs *

This LOA revokes all previous LOAs for interexchange and/or local service provided to the BTNs/WTNs identified above.

I understand and agree.

I do not understand or agree. (Smartaira will be unable to proceed.)

Effective Date and Term of Agency *

This LOA takes effect on and will remain in effect until cancelled or revoked by Customer.

I understand and agree.

I do not understand or agree. (Smartaira will be unable to proceed.)