Items marked by a red asterisk (*) are required.

		* CLEC Company Name: * Action Type: - select an action type - Escalation Dispute Entering a change request number is optional, but you are required to select a status (select "no change request number" if you choose not to enter a number). Change Request Number: * Change Request Status: - select one - Submitted Clarification Evaluation Presented Pending Prioritization Prioritized Development CLEC Test Completed Denied Deferred Pending Withdrawn Withdrawn * Description: * History of Item: * Reason for Escalation / Dispute: * Business Need and Impact: * Desired CLEC Resolution: Lead Submitter Contact Information * Name: * Title: * Phone Number: * E-mail Address: Joint Submitter Contact Information Name: E-mail Address: Name: E-mail Address: Name: E-mail Address: Name: E-mail Address: