User Notification Modification Form

Modify ReliaTel User Notification Information

Required fields are indicated with an *

Company Information:

*Company Name:

*Company Address:

*Company City:

*Company State:

*Date of Request:

Requestor Information:

*Requestor Name:

*Requestor E-mail Address:

*Requestor Phone:

* Effective Date of Change:

Modification Confirmation Email Information:

*Send Change
Confirmation E-mail To:

Requestor

Other(s)

Requestor + Other(s)

Note: Based on selection above, confirming emails will be sent to the following other email addresses:

First Other E-mail:

Second Other E-mail:

Third Other E-mail:

Existing User Notification Information:

*Existing User Name:

*Existing User Notify Method:

Select one:

E-Mail

Cell

Pager

Note: Based on selection above, fill in existing notification information in the appropriate field:

Existing Email:

Existing Cell:

Existing Pager:

Modified User Notification Information:

*Modified User Name:

*Modified User Notify Method:

Select one

E-mail

Cell

Pager

Note: Based on selection above, fill in modified notification information in the appropriate field:

Modified Email:

Modified Cell:

Modified Pager:

*Days/Hours to be Substituted: