US Network | Long Distance Special Pricing Request Form

LD Special Pricing Request Form

Account Executive Information

First Name

Last Name

Email
*

Sales manager

Date
*

Business Information

Business Name
*

Contact Name

Contact Phone Number

Address

Address Line 2

City
*

State

Postal Code

Current Customer

Yes

Original Sign Date

Last Name

Expiration Date

Title

BTN
*

Sign Authority

Yes

LEC(s)
*

Phone

Flat Rate Request

Any Other Information or Request

Authorized Signer

Authorized Signer Title

Authorized Signer’s Email

Account Information:

TGN Client Profile Form Started? If yes, fax to VP @ 248-458-2504

Yes

Proposal Completion Date Date

Proposal Submission Date to VP

Other Sales Opportunities (FLWB,DATA,Internet)

Out- Bount +1 (Minutes list dedicated/ switched)

In-State

Inter-State

Inbound Toll Free (Minutes list dedicated/ switched)

In-State

Inter-State

Estimated Gross Commision

Additional Contract Info

Inter-State

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