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Mark Type Of Provider/Authority You Are Relinquishing: ILEC Under ...
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ON Providers should file five (5) paper copies of each form with supporting documentation and one unofficial electronic copy in PDF format on disk. Mark Type of Provider/Authority you are Relinquishing: ILEC under Alternative Regulation Rural ILEC or Coop CLEC- Facilities Based with ETC Designation I. Contact Information Legal Name of Company: Name under which the company does business in Indiana: Company Address: Parent Company (if applicable): Telephone Number: Fax Number: E-mail Addr.
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