Wholesale: Products & Services

Disconnect Payphone Services Order

This form is to be used by Vendors and End Users to request Payphone service changes.

* denotes a required field.

State Public Service Commission Certificate Number (if applicable):
Order Activity: *
Existing Telephone Numbers to perform activity requested: *
Date Ordered: *
Desired Due Date: *

Confirmation Type: *
E-mail Address:
FAX Tel #:

Location Name: *
Location Address: *
City: *
State: *
ZIP: *
Quantity of Lines: *
Billing Name of Payphone Company: *
Billing Contact Name: *
Billing Contact Telephone Number: *
Billing Address: *
City: *
State: *
ZIP: *

Major Account Number if Applicable:
MDES Number if Applicable:
Purchase Order Number: *
Related Purchase Order Number:
Vendor Name: *
Vendor Contact Number: *

Comments and Special Instructions:
Do you have this customer's LOA? *
If yes, please qualify with one of the following:
Blanket LOA on file with CenturyLink
Will be faxing customer LOA to 866-764-8609