Request For Immediate Private Line & MPLS Information
Name of Business
Your First Name
Your Last Name
Phone Number to Contact You
ext.
Your Title
Your Address
City
State
--
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Country
United States
Canada
India
Japan
United Kingdom
Other (please specify in Comments below)
Your E-Mail Address
Phone number at site for this service?
Service of greatest interest
Choose From List
T1 Dedicated Private Line
T1 MPLS Virtual Private Line
T1 Best Option: Dedicated or MPLS Private Line
T3 Dedicated Private Line
T3 MPLS Virtual Private Line
T3 Best Option: Dedicated or MPLS Private Line
International Private Line (Best Option)
Other (Please Describe in Comments Below)
Computers at site of connection?
Choose From List
Less than 5
5 to 20
20 to 100
More than 100
Primary use of connection?
Choose From List
Web Browsing/E-mail
Communicate with Branch Offices
Communicate with Headquarters
Application Hosting
Web Site Hosting
Integrated Voice and Data
Voice Only
VOIP (Voice Over IP)
Communicate with Suppliers
Other
Where will this connection be?
Choose From List:
Office
Office in Home
Residential use
How many locations are part of this request?
Choose from List
1 Location
2 to 5 Locations
5 to 10 Locations
10 to 20 Locations
20 to 50 Locations
50 to 100 Locations
More Than 100 Locations
Timing of your buying decision?
Choose From List
Within two weeks
ASAP!! This is an emergency!
Within one month
Within three months
Within six months
Not yet decided
Current Internet connection?
Choose From List
DSL
Dial-Up
ISDN
Satellite
Full T1
Fractional T1
Frame Relay
Other
Do you have an existing contract for private line services?
Choose Below
No
Yes
If so, when does your current contract expire?
Choose From List
August 2003
September 2003
October 2003
November 2003
December 2003
In six months or more
No contract in place
Comments: