Service Provisioning Order

Service Provisioning Order

Installation Information

Installation company name:

Industry:

Street address:

City, State, Zip:

, -

Main phone number at site:

( ) - (This phone must be a landline phone terminating at site)

Site contact name (for inside wiring):

Site contact phone number:

Site type

If residence, is it a rental or part of a homeowners association?

No Yes (Letter of Agency required for installation)

Does Contractor need proof of insurance to enter premises?

No Yes (Letter of Agency required for installation)

Preferred installation (*Surcharge applies)

Additional information (e.g. access, limitations, special instructions):

Order Information

For adds and conversions:
Order type:
Promotion (if applicable)

Desired speed:
Minimum acceptable speed:
Service term
Intended CPE
PVC Requirement

For conversion of existing telephone line:
Phone no. of line to be converted:

For speed changes, disconnections, or moves:
DSL Access Device serial number:

For speed changes:
	From to

Your Information

Your company name:

Provisioning contact name:
List two ways to communicate with the provisioning contact:
Email:


Technical contact name:
List two ways to communicate with the technical contact:
Email:

Days and hours of availability:

Salesperson

Note

Unfortunately orders we receive after 2:30 pm PT won't make the phone company cutoff time and will be processed on the following day.

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Form last updated on 17 Sep 1998 19:28:17 -0700