Panix T1 Order Form

   Panix, New York's first Internet Service Provider

Please do not fill out this form until you are ready to place an order. Upon receipt of this order submission, we will send you a completed contract. Your leased line will be ordered upon receipt of the signed contract.

If you have any questions about filling out this form, please feel free to contact us.

Installation Information

All bold-face fields are required. The remaining fields are supplementary & any information given can only speed your order.

   
 

Company Information
Domain name
Company name
 

Location where circuit will terminate
Company name (if different from above)
Contact name
Contact phone
Contact fax or alternate number
Contact email
Street address
Floor
Location on floor
City State Zip
-
Phone number at installation site
 

Technical contact
If tech contact is the same as site contact, check here.
Name
Email
Phone
Alternate Phone or Fax
Street address
City State Zip
 

Administrative contact
If tech contact is the same as site contact, check here.
Name
Email
Phone
Alternate Phone or Fax
Street address
City State Zip
 

Billing contact
Name
Email
Phone
Alternate Phone or Fax
Street address
City, State, ZIP
 

Desired bandwidth

Network size
Number of machines now
Number expected six months from now
Do you want a Panix newsfeed? Yes  No 
Primary domain name service by Panix? Yes  No 
Name-server:
Do you need IP addresses from Panix Yes  No 
Can you use Network Address Translation? Yes  No 
 

Hardware
Which router do you want?
 
 
 

Invoice delivery
Email only
Postal and email 
 

Other
How did you learn of Panix?
Anything else we should know?
 

Finished?
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webmaster@panix.com | Last modified: Wednesday, 28-Nov-2007 12:21:39 EST

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