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Customer Information Request Form
Customer Info
Business Name
*
Physical Address
*
City
*
State
*
ZIP
*
Phone
*
Fax
Contact First Name
*
Last Name
*
PBX Make
Additional Locations
Address & Main Number
Address & Main Number
Address & Main Number
Address & Main Number
Address & Main Number
Address & Main Number
Interconnect Info
Company Name
*
Rep Name
*
Rep Email
Date of Appointment to Propose
Services Requested
Voice
Native
PRI
Analog
N/A
SIP Trunks (Qty)
DID's (Qty)
DID Numbers (Qty)
DID Numbers to be Ported (Qty)
POTS (Qty)
Used for:
Fax
Alarm
Other
Toll Free (Qty)
Native
PRI
Analog
N/A
Dynamic T1 - Trunks (Qty)
PRI T1 - Circuit (Qty)
Data
ADSL Speeds
(ex. 1.5M/896K)
SDSL Speeds
(ex. 1.5M/1.5M)
Cable Speeds
(ex. 10M/2M)
Data T Speeds
(ex. 3M/3M)
P2P T1 (Location A)
(Location B)
MPLS (Location A)
(Location B)
Type of Circuit
Please Select
Managed
QoS
Plain Internet
Notes
Does the customer have the following?
Alarm
Yes
No
Not Known
Security System
Yes
No
Not Known
Brief description of what you need us to do:
Attach Connectivity Bills Here: