Please complete the following form. Use one form per block NXX-X request per rate center code request. Mail or fax the completed form to the Number Pooling Administrator.

The applicant is on notice that block assignments are granted subject to the condition that all block holders are subject to the assignment guidelines which are published and available from the Number Pooling Administrator. In a non-jeopardy situation, a block assigned to an entity, either directly by the Number Pooling Administrator or through transfer from another entity, should be placed in service within 6 months after the initially published effective date.

These guidelines may be modified from time-to-time. The assignment guidelines in effect shall apply equally to all applicants and all existing code block holders.

The applicant and the Number Pooling Administrator acknowledge that the information contained on this request form is sensitive and will be treated as confidential. Prior to confirmation the information in this form will only be shared with the appropriate administrator and/or regulators. Information requested for RDBS and BRIDS will become available to the public upon input into those systems.

I hereby certify that the following information requesting an block NXX-X code is true and accurate to the best of my knowledge and that this application has been prepared in accordance with most current Number Pooling Thousands Block (NXX-X) Assignment Guidelines in effect.

It is understood that the applicant will return the block NXX-X to the administrator for reassignment in accordance with block recovery procedures outlined in the guidelines.

________________________________

Signature of Authorized Representative of Block Applicant

________________________________

Title

________________________________

Date

• • 1.0 GENERAL INFORMATION

    1.1 Contact information:

    Block Applicant

    Entity Name: ________________________________________

    Contact Name:_______________________________________

    Address:____________________________________________

    City, State, ZIP:_______________________________________

    Phone:______________FAX:____________ E-Mail ___________________

Number Pooling Administrator

• • Name:______________________________________________

    Address:____________________________________________

    City, State, ZIP:_______________________________________

    Phone:_____________ FAX:___________________________ E-Mail ________________________

2. NPA: ____ Number of Blocks Requested _________ LATA: ____ OCN: ______ COC _______

• • LRN Needed _____ LRN Number ____________ LRN Effective Date _______________
    • • Switch Identification (Switching Entity / POI): ________________
    • • Switch LNP Effective Date ___________

        City or Wire Center Name ___________________

        Rate Center ___________________

    Sub Zone _________________

    Homing Tandem Operating Company: _____________ Tandem Homing CLLI: ___________

    Route same as: NPA___ NXX-X ____Use Same Route & Rate Center as: NPA ____ NXX ____

1.3 Dates

Date of Application _____________________ _ _______ RRequested Effective Date _____________ ________

• • Acknowledgment and indication of disposition of this application will be provided to applicant within ten working days from the date of receipt of this application.

    1.4 Type of Entity Requesting the Block:

    a) Local Exchange Carrier ___ CMRS ___ Other Local Common Carrier ___ Cellular Carrier ___ Radio Common Carrier (non-cellular) ___

    Interexchange Carrier ___ Other (specify) _________________________

    b) Type of service for which block is being requested:

    ______________________________________________________

    ______________________________________________________

    • c) · Is certification or authorization required to provide this type of service in the relevant geographic area? Yes _____ No _____
      • (1) If no, explain:

      ______________________________________________________

      ______________________________________________________

      • (2) If yes, does your company have such certification or authorization?

        Yes ____ No _____

        • (i) If yes, indicate type and date of certification or authorization (e.g. regulatory authorization, license, tariff, etc.):

          ________________________________________________________________________

          ________________________________________________________________________

      • • (ii) If no, explain:

          _______________________________________________________________

          _________

          ________________________________________________________________________

      d) Blocks (NXX-X) Assignment Preference ____ (optional)

      e) Blocks (NXX-X) that are undesirable for this assignment, if any ___________________

      1.5 Type of Request (Select One):

      • _____ Initial block NXX-X for new switching entity or new point of interconnection (Complete Part 2)

        _____ Block NXX-X request for New Application for existing switching entity or point of interconnection (Applicant must complete Section 1.7)

        _____ Additional block NXX-X for growth (Applicant must complete Section 1.6)

        _____ Update information (Complete Section 2) (Block NXX-X) requiring update _____

        _____ Block Reservation only:

        _____ Initial NXX-X

        _____ New Application (Complete Section 1.7)

        _____ Growth (Complete Section 1.6)

    1.6 Additional Block NXX-X Request for Growth)

    Basis of eligibility for an additional NXX-X for growth assigned to the switching entity/POI assumes the following: the initial NXX-X or the NXX-X previously assigned to a new application meets the exhaust criteria, as specified in the Number Pooling (NXX-X) Assignment Guidelines, depending on whether the NPA-NXX-X is in a non-jeopardy situation or a jeopardy situation as described in of the guidelines. The appropriate situation shall be indicated below (select one).

    ____ Non-Jeopardy NPA/Rate Center Situation

    • • I hereby certify that the existing blocks NXX-X at this switching entity/POI is/(are) projected to exhaust within 3 months of the date of this application. This fact is documented on Appendix A and will be supplied to an auditor when requested to do so per the guidelines.

    ____ Jeopardy NPA/Rate Center Situation

    • • I hereby certify that the existing blocks NXX-X at this switching entity/POI is/(are) projected to exhaust within 3 months of the date of this application. This fact is documented on Appendix A and will be supplied to an auditor when requested to do so per the guidelines.

    1.7 NXX-X Request for New Application

    Basis of eligibility for an additional block NXX-X means that there has not been an NXX-X assigned to this switching entity/point of interconnection for this purpose. (Check the applicable space and, if applicable, provide the requested information).

    ______NXX-X is necessary for distinct routing, rating or billing purposes

    • • _____________________________________________________________________

        _______________________________________________________________________________________

    ____ Other (Explanation required)

    • • The applicant must provide an explanation of why existing resources assigned to that entity cannot satisfy this requirement.

        ____________________________________________________________________

        ______________________________________________________________________________________

    1.8 Authorization for entry of RDBS and BRIDS information (Check applicable space).

    • • _____ I have attached a completed Part 2 of this form. This is the Pooling Administrator's authorization to input/revise the indicated RDBS and/or BRIDS data. Further, I understand that the Pooling Administrator may not be the authorized party to input the data. The authorization and/or data input responsibilities are determined on an Operating Company Number level. If the Pooling Administrator advises me that said Pooling Administrator does not have Administrative Operating Company Number (AOCN) responsibility for my data inputs, I will contact Bellcore-TRA to determine the correct AOCN company. Upon that determination, I will submit Part 2 directly to the AOCN company for input to RDBS and BRIDS.

        _____ Part 2 of this form is not attached. RDBS and BRIDS input will be the responsibility of the applicant.