Current Retailer Name Address Contact Email New Retailer Name Address Contact Email Site address to register against numbers Building Name Street Name Town/City County Post Code Numbers to be Ported No 1 No 2 No 3 No 4 No 5 MBN-Main Billing number-If known (Geo only) Customer’s Company Details Company Name Billing Address Town/City County Post Code Company Registration No. Billing Account No. Requester’s Details Print Name Job title Email Date Clear Submit
