HomeMy WebLinkAboutPOWERNET powernet Powernet SIP Services Order
Enabling you to connect.
ORDER INFORMATION
Customer Type: New Order Type: Quote Number:
Account#: Requested Due Date: ASAP
(choose interval of 30-45 business days)
Date: Would the Customer like to Expedite? [}'es
Note:If choosing"yes",additional fees will apply.
Carrier: Powernet
Contract Term:
AGENT INFORMATION
Name: Phone:
Email: Fax:
Manager: Dan Firehammer Agent ID:
CUSTOMER INFORMATION
Customer Name: City of Jeffersonville Phone: 812-285-6400
Contact Name: Matt Dyer Address: 500 Quartermaster Square
Contact Email: mdyer@cityofjeff.net
Contact Phone: 502-280-4744 City/State: Jeffersonville,IN Zip: 47130
Technical Contact: Joe Leachman Email: jleachman@hardycc.com Phone: 502-939-7503
Is Technical Contact Email valid for all service locations? Q'es Olo
Billing Contact Name: Matt Dyer Email: mdyer@cityofjeff.net Phone: 812-280-4744
SERVICE/ACCESS LOCATION
Site Contact Name: Site Contact Phone:
Site Address: Suite/Floor:
City,State: Zip:
COMMENTS
SERVICES REQUIRED(At least one must be selected)
Outbound SIP LD: ❑ Local(SIP Lines E911 Included): E Inbound SIP Toll Free LD: ❑
ITFS/Intl DIDs: ❑ PowerConnect: LJ Inbound SIP DIDs: LJ
OUTBOUND SIP LD
Outbound SIP Interstate Rate:
Outbound SIP Intrastate Rate:
"'If customer will require offshore international service,please populate the rates below:
Canada: US Virgin Isles: Puerto Rico:
Alaska: Hawaii:
SIP LINES
#of SIP Lines: 30 Installation NRC: $0.00
Monthly Recurring Charge(per line): $11.99 Porting NRC(per ported#): $0.00
Additional DIDs(max 20): 0 Outbound Interstate Rate:
Monthly Recurring Charge(per DID): $0.50 Outbound Intrastate Rate:
Total MRC: $359.70 Total NRC: $0.00
INBOUND SIP TOLL FREE
Toll Free Inbound Interstate Rate: $0.0129
Toll Free Inbound Intrastate Rate: $0.0129
"'If customer will require offshore international service,please populate the rates below:
Canada: $0.0231 US Virgin Isles: $0.0732 Puerto Rico: $0.0538
Alaska: $0.3174 Hawaii: $0.0923
Toll Free#5 Required:
MRC Per Toll Free#: $1.00
Total MRC: $0.00
INBOUND SIP DIDS
Domestic Rates Inbound Usage Rate: New#s Required:
Porting NRC(per ported#): Ported#s Required:
DID MRC(per#):
Total MRC: $0.00 Total NRC: $0.00
Equipment(MRC)
Adtran 908e(refurbished)
INTERNATIONAL TOLL FREE SERVICE/INTERNATIONAL DIDS
Type CountryAE: Rate MRC NRC Quant/
Total: $0.00 $0.00
TOTAL CHARGES
Total MRC: $359.70 Total NRC: $0.00
TERMS AND CONDITIONS
This Service Order is subject to and made a part of the Dedicated Master Services Agreement and the Powernet SIP Services Schedule/etween Powernet and Customer. By executing and
submitting this Service Order,Customer confirms that he/she has read the Dedicated Master Services Agreement and the •wernet SIP S: ices Schedule found at
http:/lwww.powernetco.com/page/legal,and agrees to be bound thereby and by the terms and conditions contained in this Ser ice r,.er. Powemet•acceptance of this Service Order is
subject to a technical review. Customer certifies that the information contained in this form is true,accurate,and complete to the Ikst• ustomer's kn. ledge and that he/she has been duly
authorized to execute this Service Order on Customer's behalf.
Powernet Customer t /
nature: Signature: v • U
Title: Title: lin( (,(1-Zr.
/c9 -/8.(A
Date: Date:
FOR Powernet USE ONLY
Is order an ICB? [des Flo Technical Form attached? Des Do
powernef Powernet SIP Gateway Long Distance Technical Order Information
Enabling you to connect.
CUSTOMER INFORMATION
Customer Name: City of Jeffersonville Phone: 812-285-6400
DEMARC INFORMATION
Building: stand alone Floor: 2nd Suite/Room#:
Wall: Closet: MDF
Powemet to extend
demarc?: No V Business Hours: 8:00 V am v to: 5:00 V pm V
Days: Mon V through: r" V
`NOTE: Customer is responsible for Demarc Extension Charge.
ISDN/PRI INFORMATION
Is Customer Choosing ISDN/PRI? aes al° If choosing"yes"please complete this section:
Equipment Type: Baud Rate:
(Default:64K)
Primary D Channel Assignment: Protocol: V
(Default:24th channel) - -
Does customer support Dyes i
NFAS?: Choosing"no"will default to FAS
Are Backup D Channel(s) oyes uv°
Needed?: If yes,#of Backup D Channel(s)Needed: V Other:
If Yes,Which Channel s?:
TOLL-FREE NUMBER(S)TO BE PORTED (SEPARATE RESPORG FORM MUST BE COMPLETED FOR TOLL-FREE)
Toll Free Number: Ring to: Current Provider
Toll Free Number: Ring to: Current Provider:
Toll Free Number: Ring to: Current Provider:
TRAFFIC FORECAST
Total Minutes: %Interstate: %Intrastate
COMMENTS
powerne I SIP Line Technical Information
Enabling you to connect.
CUSTOMER INFORMATION
Technical Contact: Joe Leachman Technical Phone: 502-939-7503
On-Site Contact: Matt Dyer On-Site Phone: 812-280-4744
Of different from Technical Contact)
Emergency Contact: Matt Dyer Emergency Phone: 502-533-5576
•(RECTORY ASSISTANCE LISTING
Would you like to retain your existing directory listing? 0,'es Duo
Customers in CINCINNATI,OH:Please provide the following information:
Published in the Directory? Oyes pio Yellow Page Category:
Listed Name&Address:
• • If - - • _ -•- • •. 1-- -'•l :ILL - •11-
Telephone Number Current Provider Port YIN Voice or Fax Full,DID,Virtual
30 new#'s
OTHER EXISTING DEVICES
Check any existing devices you have and explain how each will be handled below.
Credit Card ❑ Postage Meter ❑ Alarm System ❑ Modem ❑
DEVICE EXPLANATION(i.e.will you keep an analog line in place for your alarm or do you need another solution?):
COMMENTS
powernef
Enabling you to connect.
Commercial Credit Application
l �
Circuit Type: • PNG Quote Number
.WI
Product Type: yoke • Equipment Needed Des Ek
New Service?des Qlo Will PNG Provide Loop?Des 0!o
Term of Usage: V Estimated Voice Usage(in$): $500.00
MRC Cost: $400.00 International Traffic?Des Die
NRC Cost: If yes,provide estimated monthly usage:
Customer Type: New •1 Account Number. --�
II STOMER INFORMATION
Customer Legal Name: City of Jeffersonville
Tax Identification or ss.#: Physical Address:1500 Quartermaster Court
DUN's#lif applicable)" I City/State:IJeffersonvllle
Phone:I 812-285-6400 I County: United States Zip: 47130
AKA/DBA Name:I 1 Billing Address:I(Same as above)
Parent Company Name:I I City/State:
President/Owner I Mayor I County: Zip:
Nature of Business: Government
Note:If any party other than the Corporation will be assuming fina;,ncial responsibility,please complete a Personal Guarantee Form.
..u ...-+..,.a a Ea`. . ... ' €3`� :.r a: `''r'$4'tYd
Proprietorship: ❑ Corporation: ❑ Previous Address
lit at current address
less than 5 years)
General Partnership: ❑ Not for Profit: ❑
Limited Partnership: ❑ Limited Liability: 0 City/State:I Jeffersonville/Indiana
County: Clark Zip: 47130
State/Local Government: City of Jeffersonville State of Inc.: Indiana Date of Inc.: 01/01/1802
t n �, sr I
Contact Name: Matt Dyer
Contact Title:I Director of I.T. I Contact Phone: 812-280-4744 Email: mdyer@cityofjeff.net
Billing Contact Hope Northam Billing Phone! 812-285-6425 I Email: hnortham@cityofjeff.net
Public Company? Des ao Years in Business:I 216 Years I
Ever filed Bankrupty? Des Db Date previously filed Bankruptcy:
Product(s)under Contract: Di Om D53 DOM ❑p only Number of Employees:I 400
Estimated Current Usage in($):I $ 3,000.00 I Length of Current Contract:I 1 Year
Previous Carrier: ( AT&T I Other:
Commercial Credit Application Customer Initials
powernet�
Enabling you to connect.
Commercial Credit Application
�.m
Company Name:I John Deere Financial Phone Number. 800-866-4501
Contact Name: Fax Number:
Address: P.O.Box 4450 Zip: 60197
City/State: Carol Stream,Illinois Highest Credit:
Contact Email:
Company Name: Jacobi Toombs+Lanz Inc. Phone Number 812-945-6782
Contact Name: Fax Number:
Address: 1829 E.Spring St.Suite 201 Zip: 47150
City/State: New Albany,Indiana Highest Credit:
Contact Email:
Company Name: Chase Credit Card Phone Number: 800-432-3117
Contact Name: Fax Number.
Address: P.O.Box 6294 Zip:' 60197
City/State:l Carol Stream,Illinois Highest Credit:
Contact Email r
Date Received u ` Date Approved: Approved: Des Do
Reference Check Positive Ijiegative Dnreturned D&B Info.:I
Letter of Credit Required? Des ❑ro Amount: OR Line of Credit Extended:
Prepaid Only: Des Do
This Credit Application must be submitted with 1)copies of Applicant's three(3)most recent telecommunications bills.Such bills must be for services
equivalent to the services Applicant requests PNG to provide,and must reflect Applicant's account status;and 2)a completed PNG Services Agreement and
all associated order forms. Submit this form with the required attachments via FAX to PNG Dedicated Sales Support.
"This Credit Application does not constitute an order for service or indicate PowerNet Global's acceptance of any service order or Services Agreement submitted by Applicant.Applicant may be requested to
provide additional information to complete this credit check.
"Payment shall be due and payable in accordance with any applicable Services Agreement,service schedules or service orders that may be executed between PNG and Applicant.
"Applicant agrees that the terms herein are subject to change at any• eat PowerNet Global's sole discretion.
"By signing this credit application,Applicant authorizes PowerNet G.•'i to conduct all credit investigations and verify any credit information from whatever source PowerNet Global deems necessary,and
further authorizes PowerNet Global to investigate the refere ces,st ents or other data listed or accompanying this application.Applicant certifies that the information contained in this credit application is
true,accurate and complete to the best of Applicant's kno -dge. -nt's signature attes the entity's financial responsibility,ability,and willingness to pay all invoices in accordance with PowerNet Global's
terms and conditions.
Customer Name: 11111111117:41211AfTrj( / Title:I 7-
7
Customer Signature: 1 Date:
Commercial Credit Application Customer Initials