WAN Service Request Form (STS01) Date: / / Page 1 Telephone: (919) 754-6000 Billing Location Code (ITS Use): Office of Information Technology Services Telecommunications Services Fax: (919) 850-2828 PO Box 17209 NSWAN Site number: Raleigh, North Carolina 27619-7209 SLA (ITS Use): Individual / Global Service request number (ITS Use): ITS Home Page Service Level Agreement Please answer all questions below to expedite processing of this order. Please print or type. Requestor Name: Requestor Daytime Telephone Number: ( ) - Requestor E-mail: Requestor Fax Number: ( ) - Department Code: (billing information) Department Name: Division: Federal ID: Bill -To Telephone Number: ( ) - (Telephone number to install DSL service) *ITS will perform this change during New Termination Change (Specify Upgrade, Relocate or Billing): business hours, unless otherwise specified in Remarks/Special Instructions below. WAN: 64K 128K 256K 1.5M 3M L2 Metro: 100M Small Office 6M 10M 20M 45M 100M 1G Broadband QoS Template: Number of devices: Site Name (Project): Street Address: City: County: Zip Code: Room: Wiring Closet: Site Contact Name: Site Contact Fax Number: ( ) - Site Contact E-mail: Site Office Hours: Site Contact Telephone Number: ( ) - Contact Telephone Number: ( ) - Site Technical Contact Name: Site Telephone Number: ( ) - Site Technical Contact E-mail: Site Technical Contact Telephone Number: ( ) - Remarks / Special Instructions: Customer Information and Responsibilities • WAN service installation occurs between 45 – 60 days from the date of the FULLY COMPLETED request form. Typical service termination occurs between 30 – 45 days from date of request. (NOTE: Service targets will be extended if FULLY COMPLETED request forms are NOT submitted) • Please be specific in your description of the Building and Room # (Address of Service Installation) to ensure the data circuit is installed within 5 feet of the rack where the router and CSU/DSU are to be placed. If information is not completed correctly, then service installation dates will be extended beyond 45 – 60 days. • Provided that a signature is on file, customers may email this form to the following address – email@example.com • Customer acknowledges they have read and understood the terms and provisions in the Service Level Agreement (SLA) and accepts the terms and conditions as indicated. Fiscal Office/Budget Authorization Signature: _____________________________________________ Signature on File This STS01 Form supersedes all other versions. STS01 Version (Date) 4/1/09.
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