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Name of Business
Phone Number to Contact You		ext.
First Name
Last Name
Title
Address
City		State NY 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
Your E-Mail Address
Phone number at the location?
Primary Service		Choose From List Full T1 Fractional T1 T1 with VPN VPN Only Point-To-Point Multiple T1's DSL Fatpipe Packeteer Voice Frame Relay Co-location Managed Hosting Private Line Off Site Data Storage Other
Secondary Service		Choose From List Full T1 Fractional T1 T1 with VPN VPN Only Point-To-Point Multiple T1's DSL Fatpipe Packeteer Voice Frame Relay Co-location Managed Hosting Private Line Off Site Data Storage Other
Number of users at connection site?		Choose From List Less than 5 5 to 20 20 to 100 More than 100
Primary use for this connection?		Choose From List Web Browsing/E-mail Communicate with Branch Offices Communicate with Headquarters Application Hosting Web Site Hosting Integrated Voice and Data Communicate with Suppliers Financial Processing Other
Where will this connection be?		Choose From List: Main Office Remote Office International Office
Current connection?		Choose From List DSL Dial-Up ISDN Satellite Full T1 Fractional T1 Frame Relay T3 Multi-T1 Other
Current access providers?
How many locations?		Choose from List Under 50 50 - 100 101 - 250 251 - 500 501 plus
Timing of your purchase decision?		Choose From List ASAP!! This is an emergency! Within two weeks Within one month Within three months Within six months Not yet decided
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