Panix Business Express DSL Order Form

Name of company or organization:

Domain name:

Street address:
Select Suite Room Apt Unit Other

If the installation site has more than one floor, please include the floor number.
Floor:

City, State, Zip:
, -

Main phone number at site:
- (This phone must be a landline phone terminating at site)

Industry:
- Select one - Accommodation and Foodservices Administrative and Support, Waste Mgt and Remediation Svcs Agriculture, Forestry, Fishing, and Hunting Arts, Entertainment and Recreation Construction Educational Services Finance and Insurance Health Care and Social Assistance Information Management of Companies and Enterprises Manufacturing Professional, Scientific and Technical Services Public Administration Real Estate and Rental and Leasing Retail Trade Transportation Utilities Wholesale Trade Other Services (except Public Administration) Unclassified Establishments

Where Did You First Hear about Panix sDSL?
- Select one - ad in The Onion Panix homepage, newsgroup, etc. Panix subscriber From a friend or associate dslreports website Banner ad on a website Other website Other / Can't recall

On-site contact for your installation

Site contact email address:

Site contact name:

Site contact phone number:

Site contact alternate phone number:

Site contact fax number:

Preferred means of contact:
primary phone alternate phone email

Technical contact for your installation

If tech contact is the same as on-site contact, check here.

Technical contact email address:

Technical contact name:

Technical contact phone number:

Technical contact fax or other number:

Billing contact for your installation

If billing contact is the same as on-site contact, check here.

Billing contact email address:

Billing contact name:

Billing contact phone number:

Billing contact fax:

Additional contact for your installation (optional)

Name:

Phone number:

Fax number:

Site Information

While not all of the following fields are mandatory, please provide as much information about your site as you can.

Is the site residential or business?
Residence  Business

Location of Telephone Box:
outside of building inside building basement don't know

Preferred installation time
8AM-12PM  12PM-4PM

Special instructions for access:

DSL Line Information:

Desired bandwidth*:
192 kbps 384 kbps 768 kbps 1.1 MBps 1.5 MBps

* Speeds are not guaranteed.

Minimum acceptable bandwidth:
192 kbps 384 kbps 768 kbps 1.1 MBps 1.5 MBps

Backup service?
No modem dialup single channel ISDN dual channel ISDN

All Business Express DSL orders include a separate PPP account for modem dialup access.

Network Information:

Can you use Network Address Translation? Yes No

Number of workstations now:

Number expected six months from now:

Primary domain name service by Panix?     Yes No
If yes, and if you have not already done so, please fill out our domain name registration form after you have submitted this form.

If you do not order your DSL hardware through Panix, either for outright purchase or as a Plus Package, Panix will assume that you are providing your own hardware. In this case, please specify the hardware that you will be using in our Additional Info section below.

NOTE: If you purchase hardware, you do not need the Plus Package, and vice versa.

"Plus Package" (leased hardware)	None Unlimited-user router router with ISDN card router with V.90 modem card
Purchasing hardware direct from Panix:	None Unlimited-user router router with ISDN card router with V.90 modem card

Service Information

Invoice delivery method:
Email only
Postal and email

Additional info (e.g. access, limitations, special instructions):