Qwest Wholesale Customer Service GET Accounts CenturyLink by jolinmilioncherie


									                                       Qwest Wholesale Customer Service GET Accounts
                                                    Residence Lines and
                                        Qwest Long Distance/Broadband Request Form

                   Email completed form to dulisp2@qwest.com For fastest service, send only one form per
                                     Order Request Information
Date Request Submitted:        Required          Requested Due Date         Required
Click to Select Order Request Type Required      PON         Required
Account Billing Telephone Number:       Required    Make a change to a pending order
for existing accounts
Leave blank for new installs                        Cancel a pending order Must be submitted a minimum of one
                                                                      day prior to due date
Do you want to add to Existing Summary Bill?         Summary Bill Number
Yes If yes provide Summary Bill Number
                                       Order Initiator Information
Order Initiator Company Name                         Customer Name                                     Required if different from initiator
must be affiliated with Customer Account                              company name
Initiator Name            Required                Initiator Email          Required           Initiator Contact Number          Required
                                           Listed and/or Service Address Information
                                                    For Directory and Directory Assistance
Customer Name         Required                                    Customer Address            Required
Service Address       Required                                    City         Required State     Required
Select Customer Directory Listing Status                          Other service at this address?
Required                                                          Provide TN:
                                                        Billing Information
Billing Name                                                      Additional Billing Name
Billing Address                                                   Billing City        State    Zip
 Will this be a Gift Billed Account?             Yes
If yes provide the Account Number
Note: New Gift Billing Account MAY require LOA
                                                        Credit Information
                            Other Service Business (OSB) Telephone Number is mandatory on ALL New Installs.
OSB of other current Qwest local business service in same name                                      Mandatory for all New Installs
If you cannot provide a local OSB in the same name, please fill out the remainder of the Credit Information section. Accounts
Payable information required.
 Owner/Officer Name                                                   TN                                       Ext
 Owner/VP Name                                                        TN                                       Ext
   Individual           Partnership                         Corp                State of                  Individual Ownership
 Ownership                                                                   Incorp
 Corporate Address
 Business Name                                                        Legal Corporate Name
 Accounts Payable Contact Name:                                       Accounts Payable Contact Number:

                                                             Revised 06/01/10
                                                          Tax Exemption Status
   Provide information to indicate applicable tax status on all New Installs. A positive entry must be made for this order request to be accepted.

Is this account to be exempt from taxes and/or regulatory charges?                           Yes         No A positive entry must be
made for this order request to be accepted. If yes, you must select the appropriate Service Provider category below
Click to Select Service Provider Category                     Provide explanation if “Other” has been selected:
                                                 Local Contact Information (LCON)
                                      Must be included for all New Installs, Move Orders, and Change Orders.
                                                     Needs to be someone on the premises
LCON Name         Required                                           LCON Number         Required
Alternate LCON Name:                                                 Alternate LCON Number:
                                                    Select Type of Residence Line
                                                            Do not put this in Remarks
Show quantity of      1FR Flat Residence                                              AFH Additional                  Broadband Line or
residence lines  Line                                                    Line                                  Digital Service Line (DSL)
    Add Features as Marked Below                                            Remove Features as Marked Below
     AFM Call Following                 AS3WL Long Distance Alert                 D7T Do Not Disturb                EO3 3-Way Call Transfer
     ES3 3-Way Calling                  ESM Call Forward                          ESX Call Waiting                  E3D 30 Number Speed Calling
     E8C 8 Number Speed                 FBJ Call Forwarding Service               LWE Long Distance Alert           NKM Caller ID Blocking
   NNK Caller ID Name &                 NSK Priority Call                         NSQ Last Call Return              NSS Continuous Redial
    NSY Call Rejection                  NSW Call Waiting ID                       N6S Caller ID with Privacy        OC4 Dial Lock
   RGG1A 1 Custom Ring                 RTY Long Distance                        RV1 Security Screen                 SB5 No Solicitation Service
Number                             Restriction                             Service
     VBS Extension Mailbox              VMJXA Voice Messaging                   VMJXB Voice Messaging
                                                                           & Visual Indicator
                                                 Select Long Distance / Call Blocking
    Add Blocking as Marked Below                                               Remove Blocking as Marked Below
      RTY Long Distance               RLZCT Long Distance Restriction           RBVXC International Toll            RTVXN Pay Per Call Restriction
Restriction                                                                Blocking                            (Long Distance Blocking)
    RTVXY Carrier Access             PROX 10XXX Carrier Access Code              SCG9X Block 900 Pay per           TBE A Restricts Collect & Third
Code Blocking                   Blocking                                   Call Non Pay                        Number Billed Calls

    TBE B Restricts Third             TBE C Restricts Collect Calls only   Optional Maintenance Plan                   DSL Data Backer
Number Billed Calls only
                                                            Select Long Distance
                             PIC = Long Distance (Interstate and Intrastate/Interlata) LPIC = (Intrastate/Intralata)
                                                 NO Long Distance = PIC NO, LPIC NO
Telephone Number                                                           PIC/LPIC
Telephone Number                                                           PIC/LPIC
Telephone Number                                                           PIC/LPIC
Fill in PIC & LPIC of the carrier of choice or if no long distance = PIC/LPIC NO
                                       If Qwest Long Distance is requested = PIC/LPIC 0236
                                               Select Qwest Long Distance Calling Plan

                                                                   Revised 06/01/10
     OE3R7                           OE3RE                                    OE3RD                                  OE3RH
5 Cent Plan                     Qwest Unlimited without local service   Qwest Unlimited with qualifying local   15 Cent Single Rate
                                package*                                service package*

   OE3R5                             OE3RF                                    PGOQU and OE3QU                       PGOQV and OE3QV
Membership Calling Plan         10 Cent Domestic                        Home Phone Unlimited with Home Phone    Home Phone Plus with Home
                                                                        local service package*                  Phone local service package*
      OE3R4 Choice                   OE3CL Plan Latino II
International calls will be billed at the default international rates for residence customers if no international plan is
selected. Rates vary by country.
Qwest Long Distance Service Agreement
By using your Service you agree to the rates, terms and conditions of the Qwest Long Distance Service Agreement,
the Qwest LD Corp. Interstate and International Rates and Services Schedule No. 1, Qwest LD Corp.’s state tariffs,
price lists, rate schedules and catalogs.

Limitations apply to all Qwest Long Distance unlimited calling plans
Direct dialed voice calls only.
         The term direct dialed voice calls does not include the following types of calls: prolonged internet use, calls to Internet
         service providers or other data service providers, multi-party conference calls (except when dialed using a toll free
         number), calls initiated by high volume auto dialers (high volume call centers), PBX, ISDN, FX, PAL, Coin, Payphones,
         Smart Payphones, Centrex, WATS, Key Systems, or ACD systems, or the functional equivalent of any such system, calls
         for the purpose of dictation or transcription, chat lines, intercom calls / monitoring calls, does not include 900 number
         calls, directory assistance, calling cards, or operator services calls.
         If a customer’s usage exceeds 5,000 minutes of use in any month the customer shall be subject to investigation to
         determine compliance with listed restrictions.
Not available in Montana and New Mexico.
Qwest Long Distance provided by Qwest LD Corp.
                                       If Qwest local long distance/toll is requested = LPIC 5123
        Residence MTS (no             OLGVX Super Savings Calling
usoc)                           Plan (All states except MN & SD)
                                OLGVX Super Savings Calling Plan
                                (MN & SD)
Qwest local long distance/toll provided by Qwest Corporation
                                                     Jack Information
Jack Quantity                                                 Extended Wiring Detail
Tag at the Dmarc?             Provide location details

This section is for information not included in available fields in the above form:

                                     Select Qwest Residence Broadband Service
                               Any available promotional offers will automatically be applied.
                    A positive entry must be made in one of the Speed selections for this order request to be accepted.
Add DSL to phone number                          Required if ordering
Select Qwest Broadband Speed Click to Select                             Select Standalone Broadband Speed Click to Select
Select Fastest Broadband Speed Click to Select                           Select Fastest Standalone Broadband Speed
Only available with Qwest as ISP- Premium Modem required                 Click to Select
                                                                         Only available with Qwest as ISP- Premium Modem required
Qwest ISP Selection              Qwest with Microsoft                    Name of ISP Selection (if not Qwest)
                                Qwest with Internet Basic

                                                                   Revised 06/01/10
                                    Please populate Ship To information so software CD can be mailed
                                        Select Length of Broadband Service Commitment
                    A positive entry must be made in one of the Commitment fields for this order request to be accepted.
      Month-to-Month Commitment                                             2 year commitment Early termination charge of
 Select Modem Type:                                                     Select Installation
    Standard Modem - Purchase                                              Qwest - Regular Technician Installation
    Standard Modem – Rental                                                Qwest - Professional Networking Installation
    Advanced Wireless Modem – Purchase                                    Self install
    Advanced Wireless Modem – Rental
     No Modem Needed
 Will more than 1 computer be connected?                  Required      Number of Computers for Networking Installation
    Yes                                                                 Click to Select
      2-Line Inline Filter            Microfilter Pack                     Wireless Laptop Card (aka           Wireless USB Adapter
                                                                        PCMCIA card)

                                  Ship-To information REQUIRED for modem to be sent
                                Qwest Broadband Modem Ship-To Information (No PO Boxes)
Ship to Name                                                         Ship to Addt’l Name
Ship to Address                                                      Ship to Address                   (Suite Number, Apt, etc.)
Ship to City                                                         State        Zip

                                         QWEST BROADBAND LEGAL AGREEMENT

Please read the terms including arbitration and limits on Qwest liability at www.qwest.com/legal ("Qwest Broadband Subscriber Agreement")
that govern your use and Qwest's provision of the service(s) and equipment you selected above.
Please also read the (1) information on term and early termination fee for the term you selected above, and (2) disclaimers and end user
license agreement related to this installation and software you receive during it, if any ("Install Agreements").
Your click on "Accept" is an electronic signature and acknowledges: (1) you agree the Qwest Agreement contains the terms under which
service and equipment are offered and provided to you, (2) you understand and agree to such terms (even if you don't read them), and (3) you
understand and agree to the Install Agreements, if applicable to you. Federal and some state laws provide for certain disclosures, and the
relevant language from the Federal Act at www.qwest.com/legal/electronicsignatures.html. You may get a paper copy of the agreements free of
charge by printing them from this page and www.qwest.com/legal. Qwest does not otherwise provide you with a paper copy. A standard
connection to the Internet/World Wide Web, a device that sends and accepts standard email, and a software program that permits you to
display standard internet websites are the only hardware/software that we know of that are needed to communicate with Qwest and access this
information in electronic form. If we change hardware/software so much that access/communication may be difficult with such
equipment/software, we'll advise you. If you do not agree to the Qwest Agreement and Install Agreements, in their entirety without modification

                                                               Revised 06/01/10
and/or do not consent to Qwest's performance of the Installation Activities or to receiving information in this install in electronic form only, click "I
Do Not Accept” below to discontinue the order process.

Your click on "Accept" is an electronic signature to the agreements and contracts set out herein.
Please review the material at www.qwest.com/legal for important, binding, legal information.
I understand these terms and accept these terms. Click to Accept

     Your request for Qwest Broadband service cannot be fulfilled without an acceptance of these terms.

                             If you have difficulty in filling out or sending this form, contact your Qwest Service Manager.

                                                                   Revised 06/01/10

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