State of Maine
Emergency Services Communication Bureau
18 State House Station
Augusta, Maine
04333-0018

VoIP Service Provider (VSP) Information Request
For Maine E9-1-1 Services (11/30/05)

Please submit the following information to the Emergency Services Communication Bureau prior to implementation:

1. VSP’s company name and corporate headquarters address

	Name: ____________________________________
	Address1: _________________________________
	Address 2: _________________________________
	City:	____________________________________
	State:  ______________  Zip: __________________

2. Name(s), telephone number (s) and email address(es) for:

•	24 x 7 Network Operation Center (NOC)
NOC Telephone:___________________________

•	Contact name(s), telephone number(s) and e-mail address(es) for those responsible for administering ALI discrepancies

Name:					Name:
Telephone:				Telephone:
Email:					Email:

•	Contact name(s), telephone number(s) and e-mail address(es) for those responsible for Liaison/Regulatory Affairs Manager

Name:					Name:
Address 1:				Address 1:
Address 2:				Address 2:
City:					City:
State:		Zip:			State:		Zip:
email:					email:

Return by FAX to: (207) 287-1039.