WinStar PacNet Electronic Order Form
Instructions
This Excel workbook contains three WinStar PacNet forms:
DATA SERVICE ORDER FORM
PVC ASSIGNMENT SHEET
CREDIT APPLICATION
Each of these form may be filled out electronically, or printed and filled
out manually, or a combination of both. Follow the instructions below.
1. Before you begin, save this file to your hard drive.
2. Select the form you want by clicking its tab below.
3. Information may be entered only into certain areas. The grey-bordered space
at the beginning of each box indicates where to begin typing. All other areas
have been password protected to eliminate inadvertent changes for the form.
4. Tab from one active cell to the next or use your cursor.
5. To use the check boxes, place your cursor over the box. A little hand will
appear. Position the index finger in the center of the desired box and click.
A check mark will appear. To remove the check, click again.
6. After completing the forms electronically, SAVE AS the customer name and send
via e-mail to Heather Calvert at hcalvert@winstar.com.
7. IMPORTANT
The purpose of this electronic format is ease of entering the information and
legibility. The Data Service Order and Credit Application both require the
customer's signature. After obtaining the customer's signature, those forms
must be faxed to Heather Calvert at 206-574-3058 before the provisioning
process will begin.
8. It is not possible to copy a form and paste it to a new worksheet. Some of
the key elements of the form will be lost. The correct method is to use the
SAVE AS function and save the spreadsheet under a different name.
-----------------------------------------------------------------------------
NOTE: With Excel, what you see on your screen is not always what prints. Do
not be concerned by what seem to be errors in the form design. (The customer
agreement text on the Data Service Order Form, for instance, may look as
though it is running off the side margin.) The forms will print correctly.
-----------------------------------------------------------------------------
WINSTAR 665 Andover Park West TEL: 800-223-6893
PACNET Seattle, WA 96168 FAX: 206-574-3058
DATA SERVICES ORDER
SIGNED SERVICE AGREEMENT AND PRICING FORM MUST BE ATTACHED OR ON FILE.
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING NAME SERVICE ORDER #
CNM Network Loc B
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS CITY STATE ZIP
1900 Los Angeles Ave. 2nd Floor Simi Valley CA 93065
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING CONTACT NAME PHONE NUMBER FAX SALES REP NAME SALES REP ID#
Randy Greene 805-520-7170 805-520-7211 Joe Quenneville / /
- -----------------------------------------------------------------------------------------------------------------------------------
/X/ STANDARD INTERVAL SERVICE COMMITMENT PERIOD
REQUESTED DUE DATE: 12-01-98 / / 12 MONTH / / 24 MONTH / / 36 MONTH / / 48 MONTH / / 60 MONTH
- -----------------------------------------------------------------------------------------------------------------------------------
/ / EXPEDITED ORDER* (REQUIRES ADDITIONAL CUSTOMER SIGNATURE) CUSTOMER SIGNATURE/TITLE DATE
*THE SERVICE REQUESTED WITHIN THIS ORDER REPRESENTS AN EXPEDITED INTERVAL.
--------------------------------------------------------
THIS IS AUTHORIZATION FOR AN INTERNAL PACNET EXPEDITE AND/OR LOCAL EXCHANGE CARRIER EXPEDITE WITH ASSOCIATED CHARGES.
- -----------------------------------------------------------------------------------------------------------------------------------
SERVICE ORDER TYPE
- -----------------------------------------------------------------------------------------------------------------------------------
/X/ ORIGINAL ORDER / / CHANGE ORDER / / OTHER Point to point DS-3
/X/ Private Line / / Add PVCs / / Disconnect Site ----------------------------
/ / Frame Relay / / Change PVCs / / Disconnect PVCs ----------------------------
/ / Dedicated Internet / / Change Port Connection Speed Requested Speed / / ORIGINAL ORDER # / /
- ------------------------------------------------------------------------------------------------------------------------------------
CIRCUIT TYPE
- ------------------------------------------------------------------------------------------------------------------------------------
PRIVATE LINE / / T-1 B8ZS / / T-1 AMI / / FT-1 / / 56Kb
- ------------------------------------------------------------------------------------------------------------------------------------
FRAME RELAY / / FR T-1 / / FR Fraction Fractional Speed / / / / 56Kb / / LEC FR Access
- ------------------------------------------------------------------------------------------------------------------------------------
DEDICATED INTERNET / / INT T-1 / / INT 64/56 / / INT Fraction Fractional Speed / / / / OTHER (Specify below)
- ------------------------------------------------------------------------------------------------------------------------------------
PACNET CHARGES IXC Mileage / / REQUIRES ENGINEERING REVIEW
------------------
PACNET Quote # / / / / LD Access / / DACS-ing / / EUSA / / 56Kb
- ------------------------------------------------------------------------------------------------------------------------------------
MONTHLY RECURRING DESCRIPTION
- ------------------------------------------------------------------------------------------------------------------------------------
$ Point to Point DS-3 Between Las Vegas and Simi Valley
- ------------------------------------------------------------------------------------------------------------------------------------
$
- ------------------------------------------------------------------------------------------------------------------------------------
$
- ------------------------------------------------------------------------------------------------------------------------------------
NON-RECURRING DESCRIPTION
- ------------------------------------------------------------------------------------------------------------------------------------
$
- ------------------------------------------------------------------------------------------------------------------------------------
$
- ------------------------------------------------------------------------------------------------------------------------------------
$
- ------------------------------------------------------------------------------------------------------------------------------------
SPECIAL INSTRUCTIONS
Establish a point to point DS-3 circuit between Las Vegas and Simi Valley. Las Vegas PoP is co location space for Williams Network
Contact is Bob Frazier @ 314-506-4225 NPA NXX is 702/891 See attached quote # 16116
- ------------------------------------------------------------------------------------------------------------------------------------
LOCAL ACCESS CHARGES
- ------------------------------------------------------------------------------------------------------------------------------------
MONTHLY RECURRING DESCRIPTION PROVIDER MEET-POINT JACK TYPE
- ------------------------------------------------------------------------------------------------------------------------------------
$ Sprint
- ------------------------------------------------------------------------------------------------------------------------------------
$ LOCAL ACCESS TYPE OF SERVICE
- ------------------------------------------------------------------------------------------------------------------------------------
NON-RECURRING DESCRIPTION PRIVATE LINE FRAME RELAY OTHER
- --------------------------------------------
$ 0 Installation / / 56/64K PL / / 56K FR LOOP TERM
- -------------------------------------------- -------------------------------------
$ / / T-1 PL / / FRAC T-1 FR
- -------------------------------------------- -------------------------------------
CONTACT NAME CONTACT PHONE NUMBER / / WINSTAR WIRELESS SPEED / / CARRIER QUOTE #
- -------------------------------------------- -------------------------------------
Randy Greene 805-520-7170 LOCAL ACCESS / / T-1 FR
- ------------------------------------------------------------------------------------------------------------------------------------
ADDRESS CITY STATE ZIP
4275 East Saraha Suite 19/20 Las Vegas NV
- ------------------------------------------------------------------------------------------------------------------------------------
DEMARC LOCATION
Suite 19/20
- ------------------------------------------------------------------------------------------------------------------------------------
WinStar PACNET agrees to provide and Customer agrees to accept Services described above for the Service Commitment Period and
Charges above subject to the terms and conditions contained in the WinStar PACNET Services Agreement with the Customer # / /
and any Supplemental Agreements for WinStar PACNET services. Terms that do not conform with these Agreements shall not be binding
on WinStar PACNET and are objected to until accepted by an Authorized Headquarters Representative of WinStar PACNET.
- ------------------------------------------------------------ ------------------------------------------------------------
WINSTAR PACNET NAME/TITLE CUSTOMER NAME/TITLE
- ------------------------------------------------------------ ------------------------------------------------------------
AUTHORIZED SIGNATURE DATE AUTHORIZED SIGNATURE DATE
WINSTAR
PACNET PVC ASSIGNMENT SHEET
Customer Name
---------------------------------------------
Service Order #
---------------------------------------------
Modification Date Page of
------------------ ---- ----
PVC Requested Requested Requested Destination Node Destination Node Destination Port
Circuits New Existing CIR Committed Burst Excess Burst (City Name) # (SO) Connection Speed
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Notes
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
CREDIT APPLICATION
WINSTAR CUSTOMER AUTHORIZATION
CUSTOMER INFORMATION
COMPANY NAME
- ----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS 1
- ----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS 2
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
MAIN TELEPHONE NUMBER BILLING CONTACT FIRST NAME LAST NAME BILLING CONTACT TELEPHONE NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
PRESIDENT / OWNER / PARTNER NAME PRESIDENT / OWNER / PARTNER SOCIAL SECURITY NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
DUN & BRADSTREET NUMBER TAX ID
- ----------------------------------------------------------------------------------------------------------------------------------
TYPE OF BUSINESS YEARS IN BUSINESS BANKRUPT IN PAST THREE YEARS?
/ / YES / / NO
- ----------------------------------------------------------------------------------------------------------------------------------
LIST RELATED COMPANY NAMES WITH CITY & STATE
- ----------------------------------------------------------------------------------------------------------------------------------
HAS THE COMPANY OR ANY AFFILIATE OF THE COMPANY IF "YES," PLEASE PROVIDE NAME & WINSTAR ACCOUNT NUMBER
APPLIED FOR SERVICE WITH WINSTAR BEFORE? NAME WINSTAR ACCOUNT NUMBER
/ / YES / / NO
- ----------------------------------------------------------------------------------------------------------------------------------
BANK AND TRADE REFERENCES
- ----------------------------------------------------------------------------------------------------------------------------------
BANK NAME CHECKING ACCOUNT NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
- ----------------------------------------------------------------------------------------------------------------------------------
COMPANY NAME - TRADE 1
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
- ----------------------------------------------------------------------------------------------------------------------------------
COMPANY NAME - TRADE 2
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
I certify that I am a duly authorized representative of the company applying for telecommunications services with WinStar and/or its
affiliates, and all of the information provided is true and accurate to the best of my knowledge. Further, on behalf of the
applicant, I authorize WinStar and/or its affiliates to verify the information provided including the bank/trade references listed
on this application and through outside credit reporting agencies.
-------------------------------------------------- ---------------------------------------------------- -------------
SIGNATURE TITLE DATE
FOR INTERNAL USE
TYPE OF SERVICE BEING ORDERED
/ / Local / / Domestic LD / / Internat'l LD / / Inbound / / Outbound / / Internet / / Frame Relay / / Private Line
- ----------------------------------------------------------------------------------------------------------------------------------
NUMBER OF LINES T-1s DS-3s OTHER
/ / / / / / / /
- ----------------------------------------------------------------------------------------------------------------------------------
WINSTAR MONTHLY RECURRING CHARGE ORDER TRACKING NUMBER RELATED ORDER NUMBER
$
- ----------------------------------------------------------------------------------------------------------------------------------
ACCOUNT EXECUTIVE AE TELEPHONE NUMBER SOURCE OF SALE
/ / WINSTAR / / CUSTOMER INITIATED
- ----------------------------------------------------------------------------------------------------------------------------------
SERVICE ENGINEER SE TELEPHONE NUMBER SERVICE COORDINATOR SC TELEPHONE NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
WINSTAR-PROVIDED CPE $ AMOUNT MASTER ACCOUNT NUMBER
$
- ----------------------------------------------------------------------------------------------------------------------------------
ORDER TRACKING #
--------------------
BRANCH ID
--------------------
MASTER ACCOUNT #
--------------------
WinStar PacNet Electronic Order Form
Instructions
This Excel workbook contains three WinStar PacNet forms:
DATA SERVICE ORDER FORM
PVC ASSIGNMENT SHEET
CREDIT APPLICATION
Each of these form may be filled out electronically, or printed and filled
out manually, or a combination of both. Follow the instructions below.
1. Before you begin, save this file to your hard drive.
2. Select the form you want by clicking its tab below.
3. Information may be entered only into certain areas. The grey-bordered
space at the beginning of each box indicates where to begin typing. All
other areas have been password protected to eliminate inadvertent changes
for the form.
4. Tab from one active cell to the next or use your cursor.
5. To use the check boxes, place your cursor over the box. A little hand will
appear. Position the index finger in the center of the desired box and
click. A check mark will appear. To remove the check, click again.
6. After completing the forms electronically, Save As the customer name and
send via e-mail to Heather Calvert at hcalvert@winstar.com.
7. IMPORTANT
The purpose of this electronic format is ease of entering the information
and legibility. The Data Service Order and Credit Application both require
the customer's signature. After obtaining the customer's signature, those
forms must be faxed to Heather Calvert at 206-574-3058 before the
provisioning process will begin.
8. It is not possible to copy a form and paste it to a new worksheet. Some of
the key elements of the form will be lost. The correct method is to use
the Save As function and save the spreadsheet under a different name.
-----------------------------------------------------------------------------
NOTE: With Excel, what you see on your screen is not always what prints. Do
not be concerned by what seem to be errors in the form design. (The customer
agreement text on the Data Service Order Form, for instance, may look as
though it is running off the side margin.) The forms will print correctly.
-----------------------------------------------------------------------------
WINSTAR 665 Andover Park West TEL: 800-223-6893
PACNET Seattle, WA 96168 FAX: 206-574-3058
DATA SERVICES ORDER
SIGNED SERVICE AGREEMENT AND PRICING FORM MUST BE ATTACHED OR ON FILE.
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING NAME SERVICE ORDER #
CNM Network CNM-101
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS CITY STATE ZIP
1900 Los Angeles Ave. 2nd Floor Simi Valley CA 93065
- -----------------------------------------------------------------------------------------------------------------------------------
BILLING CONTACT NAME PHONE NUMBER FAX SALES REP NAME SALES REP ID#
Randy Greene 805-520-7170 805-520-7211 Joe Quenneville
- -----------------------------------------------------------------------------------------------------------------------------------
/X/ STANDARD INTERVAL SERVICE COMMITMENT PERIOD
REQUESTED DUE DATE: 2-01-99 / / 12 MONTH / / 24 MONTH /X/ 36 MONTH / / 48 MONTH / / 60 MONTH
- -----------------------------------------------------------------------------------------------------------------------------------
/ / EXPEDITED ORDER* (REQUIRES ADDITIONAL CUSTOMER SIGNATURE) CUSTOMER SIGNATURE/TITLE DATE
*THE SERVICE REQUESTED WITHIN THIS ORDER REPRESENTS AN EXPEDITED INTERVAL.
-----------------------------------------------------
THIS IS AUTHORIZATION FOR AN INTERNAL PACNET EXPEDITE AND/OR LOCAL EXCHANGE CARRIER EXPEDITE WITH ASSOCIATED CHARGES.
- -----------------------------------------------------------------------------------------------------------------------------------
SERVICE ORDER TYPE
- -----------------------------------------------------------------------------------------------------------------------------------
/X/ ORIGINAL ORDER / / CHANGE ORDER /X/ OTHER Point to point DS-3
/X/ Private Line / / Add PVCs / / Disconnect Site --------------------------------
/ / Frame Relay / / Change PVCs / / Disconnect PVCs --------------------------------
/ / Dedicated Internet / / Change Port Connection Speed Requested Speed/ / ORIGINAL ORDER #
- -----------------------------------------------------------------------------------------------------------------------------------
CIRCUIT TYPE
- -----------------------------------------------------------------------------------------------------------------------------------
PRIVATE LINE / / T-1 B8ZS / / T-1 AMI / / FT-1 / / 56Kb
- -----------------------------------------------------------------------------------------------------------------------------------
FRAME RELAY / / FR T-1 / / FR Fraction Fractional Speed / / 56Kb / / LEC FR Access
- -----------------------------------------------------------------------------------------------------------------------------------
DEDICATED INTERNET / / INT T-1 / / INT 64/56 / / INT Fraction Fractional Speed / / OTHER (Specify below)
- -----------------------------------------------------------------------------------------------------------------------------------
PACNET CHARGES IXC Mileage / / REQUIRES ENGINEERING REVIEW
-----------
PACNET Quote # / / / / LD Access / / DACS-ing / / EUSA / / 56Kb
- -----------------------------------------------------------------------------------------------------------------------------------
MONTHLY RECURRING DESCRIPTION
- -----------------------------------------------------------------------------------------------------------------------------------
$ 7,828.00 Point to Point DS-3 Between Las Vegas and Simi Valley
- -----------------------------------------------------------------------------------------------------------------------------------
$
- -----------------------------------------------------------------------------------------------------------------------------------
$
- -----------------------------------------------------------------------------------------------------------------------------------
NON-RECURRING DESCRIPTION
- -----------------------------------------------------------------------------------------------------------------------------------
$ 1,000.00 Installation fee
- -----------------------------------------------------------------------------------------------------------------------------------
$
- -----------------------------------------------------------------------------------------------------------------------------------
$
- -----------------------------------------------------------------------------------------------------------------------------------
SPECIAL INSTRUCTIONS
Establish a point to point DS-3 circuit between Las Vegas and Simi Valley. NPA NXX is 805-520 See attached
quote # 16116 for long haul.
- ------------------------------------------------------------------------------------------------------------------------------------
LOCAL ACCESS CHARGES
- ------------------------------------------------------------------------------------------------------------------------------------
MONTHLY RECURRING DESCRIPTION PROVIDER MEET-POINT JACK TYPE
- ------------------------------------------------------------------------------------------------------------------------------------
$ Williams
- ------------------------------------------------------------------------------------------------------------------------------------
$ LOCAL ACCESS TYPE OF SERVICE
- ------------------------------------------------------------------------------------------------------------------------------------
NON-RECURRING DESCRIPTION PRIVATE LINE FRAME RELAY OTHER
- --------------------------------------------
$ 0 Installation / / 56/64K PL / / 56K FR LOOP TERM
- -------------------------------------------- -------------------------------------
$ / / T-1 PL / / FRAC T-1 FR
- -------------------------------------------- -------------------------------------
CONTACT NAME CONTACT PHONE NUMBER / / WINSTAR WIRELESS SPEED / / CARRIER QUOTE #
- -------------------------------------------- -------------------------------------
Randy Greene 805-520-7170 LOCAL ACCESS / / T-1 FR
- ------------------------------------------------------------------------------------------------------------------------------------
ADDRESS CITY STATE ZIP
1900 Los Angeles Ave, 2nd Floor Simi Valley CA 93065
- ------------------------------------------------------------------------------------------------------------------------------------
DEMARC LOCATION
Suite 19/20
- ------------------------------------------------------------------------------------------------------------------------------------
WinStar PACNET agrees to provide and Customer agrees to accept Services described above for the Service Commitment Period and
Charges above subject to the terms and conditions contained in the WinStar PACNET Services Agreement with tand any Supplemental
Agreements for WinStar PACNET services. Terms that do not conform with these Agreements shall not be binding on WinStar PACNET and
are objected to until accepted by an Authorized Headquarters Representative of WinStar PACNET.
------------------------------------------------------------- -------------------------------------------------------------
WINSTAR PACNET NAME/TITLE CUSTOMER NAME/TITLE
------------------------------------------------------------- -------------------------------------------------------------
AUTHORIZED SIGNATURE DATE AUTHORIZED SIGNATURE DATE
WINSTAR
PACNET PVC ASSIGNMENT SHEET
Customer Name
---------------------------------------------
Service Order #
---------------------------------------------
Modification Date Page of
------------------ ---- ----
PVC Requested Requested Requested Destination Node Destination Node Destination Port
Circuits New Existing CIR Committed Burst Excess Burst (City Name) # (SO) Connection Speed
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
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- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
- ----------- ------ ---------- ---------- ------------------ -------------- ---------------- ----------------- --------------------
Notes
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
CREDIT APPLICATION
WINSTAR CUSTOMER AUTHORIZATION
CUSTOMER INFORMATION
COMPANY NAME
- ----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS 1
- ----------------------------------------------------------------------------------------------------------------------------------
BILLING ADDRESS 2
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
MAIN TELEPHONE NUMBER BILLING CONTACT FIRST NAME LAST NAME BILLING CONTACT TELEPHONE NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
PRESIDENT / OWNER / PARTNER NAME PRESIDENT / OWNER / PARTNER SOCIAL SECURITY NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
DUN & BRADSTREET NUMBER TAX ID
- ----------------------------------------------------------------------------------------------------------------------------------
TYPE OF BUSINESS YEARS IN BUSINESS BANKRUPT IN PAST THREE YEARS?
/ / YES / / NO
- ----------------------------------------------------------------------------------------------------------------------------------
LIST RELATED COMPANY NAMES WITH CITY & STATE
- ----------------------------------------------------------------------------------------------------------------------------------
HAS THE COMPANY OR ANY AFFILIATE OF THE COMPANY IF "YES," PLEASE PROVIDE NAME & WINSTAR ACCOUNT NUMBER
APPLIED FOR SERVICE WITH WINSTAR BEFORE? NAME WINSTAR ACCOUNT NUMBER
/ / YES / / NO
- ----------------------------------------------------------------------------------------------------------------------------------
BANK AND TRADE REFERENCES
- ----------------------------------------------------------------------------------------------------------------------------------
BANK NAME CHECKING ACCOUNT NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
- ----------------------------------------------------------------------------------------------------------------------------------
COMPANY NAME - TRADE 1
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
- ----------------------------------------------------------------------------------------------------------------------------------
COMPANY NAME - TRADE 2
- ----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
- ----------------------------------------------------------------------------------------------------------------------------------
CITY STATE ZIP
- ----------------------------------------------------------------------------------------------------------------------------------
CONTACT CONTACT TELEPHONE
I certify that I am a duly authorized representative of the company applying for telecommunications services with WinStar and/or its
affiliates, and all of the information provided is true and accurate to the best of my knowledge. Further, on behalf of the
applicant, I authorize WinStar and/or its affiliates to verify the information provided including the bank/trade references listed
on this application and through outside credit reporting agencies.
-------------------------------------------------- ---------------------------------------------------- -------------
SIGNATURE TITLE DATE
FOR INTERNAL USE
TYPE OF SERVICE BEING ORDERED
/ / Local / / Domestic LD / / Internat'l LD / / Inbound / / Outbound / / Internet / / Frame Relay / / Private Line
- ----------------------------------------------------------------------------------------------------------------------------------
NUMBER OF LINES T-1s DS-3s OTHER
/ / / / / / / /
- ----------------------------------------------------------------------------------------------------------------------------------
WINSTAR MONTHLY RECURRING CHARGE ORDER TRACKING NUMBER RELATED ORDER NUMBER
$
- ----------------------------------------------------------------------------------------------------------------------------------
ACCOUNT EXECUTIVE AE TELEPHONE NUMBER SOURCE OF SALE
/ / WINSTAR / / CUSTOMER INITIATED
- ----------------------------------------------------------------------------------------------------------------------------------
SERVICE ENGINEER SE TELEPHONE NUMBER SERVICE COORDINATOR SC TELEPHONE NUMBER
- ----------------------------------------------------------------------------------------------------------------------------------
WINSTAR-PROVIDED CPE $ AMOUNT MASTER ACCOUNT NUMBER
$
- ----------------------------------------------------------------------------------------------------------------------------------
ORDER TRACKING #
--------------------
BRANCH ID
--------------------
MASTER ACCOUNT #
--------------------