CityVoice: Partners | T1 Order Form

Primary Information:
Please Fill out all fields that are in Yellow or have a * next to them. All other fields are Not required.

CityVoice Order Information
Contact Number:
Customer Name:
Account Executive:
Customer Purchase Decision Date:
Customer Requested Due Date:

Customer Details
Customer Legal Name:
Customer Legal Address:
City:
State:
ZipCode:
Main Telephone:
Is Customer Tax Exempt? *
Tax Certificate Number *

Account Details
Service Billing Name:
Service MCN:
Service GRC:
Service SOC:

Billing Details
Billing Name:
Billing Contact:*
Billing Address:*
City:*
State: *
ZipCode:*
Billing Contact Telephone:*
Billing Contact Alternate Telephone:*
Fax:*
eMail:*

MIS Transport
Service Type:
Service Rate:
Service Access Type:*
Access Option:
Port Speed:
Install Type:
Service Period: *
Service Location NPA-NXX:

Service Location Details
Street Number:*
Street Directional Prefix:*
Street Name:*
Street Type:*
Street Directional Suffix:*
Street Address 1:*
Room:*
Floor:*
City:*
State:*
Zip Code:*
DMARC:*

On-Site Contact Details
First Name:*
Last Name:*
Telephone:*

Technical Contact
First Name: *
Middel Name: *
Last Name: *
Job Title: *
Salutation: *
Address:*
City:*
State: *
ZipCode:*
Telephone:*
Alternate Telephone:*
eMail:*
Pager:*
Pager PIN:*
Fax:*

Alternate Telephone
First Name: *
Middel Name: *
Last Name: *
Job Title: *
Salutation: *
Address:*
City:*
State: *
ZipCode:*
Telephone:*
Alternate Telephone:*
eMail:*
Pager:*
Pager PIN:*
Fax:*

Primary Security Contact
First Name:*
Last Name:*
Telephone:*
Alternate Telephone:*
eMail:*

Secondary Security Contact
First Name:*
Last Name:*
Telephone:*
Alternate Telephone:*
eMail:*

Additional Info:
# of LAN IP's are required:*
The standard equates to: /29 - which provides 6 usable IP's Non-standards are available at no additional cost, but should not be ordered without an immediate need. These are /28 - which provides 14 usable IP's, and /27 - which provides 30 usable IP's.
Domain Name is being used:*
AT&T to provide DNS:*

Special Notes: