ITN LD Form - Indiana Telephone NetworkIndiana Telephone Network

Submission Form for LD Only Accounts

For accounts with multiple locations, please fill out a new form for each location.

Select a contact:

Account Agent Company

Account Agent Name

Account Agent Email Address

Account Name

_{(As cust. wants displayed on Invoice)}

Account Number (5 digits)

_{(if existing account)}

Contact Person Name

Contact Person Phone

Account Password

Mailing Address Street

Mailing Address City

Mailing Address State

Mailing Address Zip

Service Location Name

Service Location Street

Service Location City

Service Location State

Service Location Zip

Current Local Carrier

PICC charges on all ANI's

PICC charge amount

Block International calls on all ANI's

ANI #1 (10 digits)		Account Code #1	Interstate rate #1
Description of usage #1		PIC #1	Intrastate rate #1

ANI #2 (10 digits)		Account Code #2	Interstate rate #2
Description of usage #2		PIC #2	Intrastate rate #2

ANI #3 (10 digits)		Account Code #3	Interstate rate #3
Description of usage #3		PIC #3	Intrastate rate #3

ANI #4 (10 digits)		Account Code #4	Interstate rate #4
Description of usage #4		PIC #4	Intrastate rate #4

ANI #5 (10 digits)		Account Code #5	Interstate rate #5
Description of usage #5		PIC #5	Intrastate rate #5

I have a signed LOA Form on file with ITN