Universal International Premium Rate Number Request Form (UIPRN)
(ITU-T Recommendation E.169.2)* (one form per number request)
To be returned with registration fee 1) to :
UIPRN Registrar
International Telecommunication Union
Telecommunication Standardization Bureau
Place des Nations
CH - 1211 GENEVA 20, Switzerland
Fax :
+41 22 730 6200
Tel: +41 22 730 6220
E-mail: universalnumbers@itu.int
Part A to be filled out by the applicant
Transmittal date: ( a)_______________
Company name
(b) _____________________________________________
Address
(c) _____________________________________________
_____________________________________________
Telephone number
(d)+____________________
Fax number
____________________
Email
____________________
Request type (mark with an X) (e)
New
Change
Disconnect
Cancel
Reason for change (f)___________________________________________________________
Universal International Premium Rate Number requests, acceptable alternatives in order of priority: (g)
1) +979 X 2) __ __ __ __ __ __ __ __
6) +979 X __ __ __ __ __ __ __ __
2) +979 X
__ __ __ __ __ __ __ __
7) +979 X __ __ __ __ __ __ __ __
3) +979 X
__ __ __ __ __ __ __ __
8) +979 X __ __ __ __ __ __ __ __
4) +979 X
__ __ __ __ __ __ __ __
9) +979 X __ __ __ __ __ __ __ __
5) +979 X
__ __ __ __ __ __ __ __
10) +979 X __ __ __ __ __ __ __ __
IPRS customer name
Customer's address
(h)____________________________________________________
______________________________________________________
______________________________________________________
Expected IPRS customer due date
(i )_____________
Is IPRS customer embedding entire existing national PRSN (j)
Yes
[ ]
No
[ ]
Existing national PRSN that is being embedded CC (k) ______ PRSN ___________________
Existing national PRSN implemented prior to 1 February 1999 (l)
Yes
[ ]
No
[ ]
Country(ies) with which the IPRS will be implemented initially (m)_____________________________
Coordination (reference) number
(n)____________________
Payment of the registration application fee: (o)_________________ Swiss francs
Specify the method of payment :
[ ] – by bank transfer to ITU account No . 240-C8-765.565.0, UBS, Geneva (Switzerland);
IBAN: CH96 0024 0240 C87655650 SWIFT No. UBSWCHZH80A Clearing No. 240
[ ] – deduction from the applicant's prepaid account
[ ] – Major Credit Card
_____________________________
1
)
the fee is currently 200 Swiss francs
*)
for service description, see also ITU-T Recommendation E.155
2
)
X is the charging indicator.