Customer Name: Date of request: Requested by:
1. Client Information
Technical Contact: Phone: Fax Number: Pager: Email: Address1: Address2: City: State: Zip: Size of network: Network Operating System: Platforms served: PC UNIX Mac Other: Type of email currently in use: Public access servers to be run on site: WWW FTP None Other: Area code of your location (NPA): Telephone exchanges of your location (NPX): Description of exact location of termination at your location: Contact for access to site (if different from above):
2. Service Type
Leased Line: 56kbps DDS T1 (Point-to-point) ISDN: 64kbps 128kbps Frame Relay: 56kpbs 128 kbps 256 kbps 512 kbps T1
3. Domain Information
4. If this is a change of provider:
Name of old provider: Existing IP addresses:
InfiNet will be pleased to help you fit these applications to your business needs. Send us an email at business@infi.net or call (757) 625-1056 or 1-800-836-3267. You can also fax us at (757) 622-7158.
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