AT&T 12-STATE
PAYPHONE SERVICE PROVIDER REQUEST FORM
1. ARE YOU A NEW VENDOR? r YES r NO
SERVICE LOCATION INFORMATION PLEASE TYPE OR PRINT CLEARLY2. Business Name:
3. Address:
4. Bldg./Suite/Apt.
5. City, State, Zip:
6. Working Number at Business Location:
7. Payphone Location (Necessary for 911 system)
r Indoor r Outdoor r Location (Rm., Flr., Etc.) / 8. DEMARC Location:
9. NI Placement (optional):
10. Access Name:
11. Access Number:
12. Type of Business: Payphone Service Provider
SERVICE & OPTIONAL FEATURES
13. # of Lines: 17. Requested Due Date:
14. Type of Request: r New r Displacement r Move r Disconnect
r Supersede
15. Long Distance & Local Toll Carrier(s)
Primary Interstate Carrier:
r None r Other*:
Primary Intrastate Carrier:
r AT&T Local r None r Other*:
Prohibit PIC Change: r Yes r No
*Note: If choosing AT&T Long Distance for Other (PIC/LPIC selections of 0288), contact AT&T at 1-888-232-9155 to discuss rate plans before submitting this form. Otherwise, you will be charged the higher default rate that can be found in the AT&T Service Guide at http://serviceguide.att.com/ABS/ext/OfferDetails.cfm?OID=327. To view the default rate, click on AT&T Business Offers on the left navigation bar and scroll down to Voice Offers. Then click on AT&T Commercial Long Distance, scroll down to Rates and Charges and click on Rate Table CLD-01.
16. Basic Service (AT&T Midwest only)
r COCOT (Smart Set) r 2 Way Service
r PPO Coin (Dumb Set) r 1 Way Service (Outgoing or Incoming Only)
r PSP Inmate r Coinless (Please check one)
18. Basic Service (AT&T California only)
Two-way Outgoing Only
r PSP Basic Line (17Q) r PSP Basic Line (18Q)
r Charge-A-Call (2CQ) r Charge-A-Call (1CQ)
r Coin Line (1PC) r Coin Line (1CC)
r PSP Inmate (1PF) r PSP Inmate (1PL)
r Inmate Collect (2PF) r Inmate Collect (2PL)
r Inmate Coin (1NC) r Inmate Coin (1PM) (Please check one)
19. Basic Service (AT&T Southwest only)
r COPT Line r 2 Way Service
r Smart Coin r 1 Way Service (Outgoing or Incoming Only)
r PSP Inmate r Coinless
r Fax / 20 PUC Certification (AT&T Southwest)
r Arkansas r Oklahoma
r Kansas r Texas
r Missouri
21. Basic Service (AT&T Nevada only)
Two-way Outgoing Only
r PSP Basic Line (19Q) r PSP Basic Line (18Q)
r Charge-A-Call (2CP) r Charge-A-Call (DDR)
r Coin Line (1PK) r Coin Line (1CK)
r PSP Inmate (1CP) r PSP Inmate (DDF)
r Enhanced (MLM) r Enhanced (MLN)
r Coin Line Flat* (1PC) r Coin Line Flat* (1CC)
*Available only in Battle Mtn., Ely & Hawthorne
(Please check one)
22. Desired Due Date: ______
23. Listing (for the Directory)
r Listed r Non-published
Listing Information:
24. Optional Services
r 900/976 Blocking r Bill to Third/Collect Blocking
r IDDD Blocking r Answer Supervision
r Per Line Blocking r RJ11C r RJ11W
r Pay Per Use r Line Backer
r Screening r OPT Call Screening (IN ONLY)
r Operator Screening (SCOCS – Southwest only)
r AT&T to do premise wire (Vendor pays for time & material)
(If AT&T to do wiring, please choose jack above RJ11C/RJ11W)
SEND BILL IN NAME OF / NAME OF BUSINESS (Vendor Information)
25. Name 1:
26. Name 2:
27. Address:
28. City, State, Zip:
29. Office Number:
30. Billing Options:
AT&T Midwest only
r Bill Under r Consolidated Summary
r Ameritech Electronic Billing Service r Electronic Data Interchange
Separate Billing r Yes r No Main Billing #: ______
AT&T Southwest only
Consolidated Bill Number: ______
CD Bill (CD ROM): r Yes r No
Special Billing Instructions: ______
AT&T California & Nev
Consolidated Bill Number: ______
CD Bill (CD ROM): with no paper copy r Yes r No
CD Bill (CD ROM): with paper copy r Yes r No
Custom Bill Disk (3.5” Diskette) r Yes r No
Stack Number: ______
Preferred Bill Date (Round): ______
Summary Billing r Yes r No
Main Summary Billing Number: (960) ______
WirePro r Yes r No
Value Promise Plus r Yes r No / 31. Name:
32. Address:
33. Contact:
34. Telephone:
35. Ownership: r Sole r Partnership
rCorporation: Year_____ State ______
36. FAX:
37. LOA: r Attached r Blanket
38. Tax ID # SSN:
39. Email Address: ______
40. Certified Check or Money Order Enclosed: r Yes, Check/Money Order
r No
41. Tax-Exempt: r Federalr Stater Municipal Utility ______
r Municipal Telecommunication Excise
DISCONNECT OR MOVE EXISTING PSP LINE / Send Final Bill to (if different from above)
42. Telephone #(s) Involved:
43. Special Instructions:
/ 44. Name:
45. Address:
46. City, State, Zip:
47. Contact Telephone:
Today’s Date: ______
SEND COMPLETED FORM TO: FOR ASC PAYPHONE SERVICES ONLY: Email Completed Form To:
AT&T-Payphone Access Service Center Assigned Order # (s):
1410 Renner Road Assigned Tel. #(s):
Rm 150
Richardson, TX 75082 Assigned Due Date:
SERVICE REP: 1 800 924-3666 Answer Supervision: r Yes r No
FAX NUMBER: 1 800 805-3555
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