Requestor Information

• Customer Name  
• Requestor Name  
• Phone Number  
• Email Address  
• Department  

General Reference Information

• System  
• CLINS ID and Case #  
• Customer Reference Number  
• Customer PO #  
• Requested Service Date  
• Requested Service Time   0102 0304 0506 0708 0910 1112 HH 00 05 10 15 20 25 30 35 40 45 50 55 MM AM PM AM/PM
• Type  
• Brief Description  

Site Information

• Agency Name  
• Site Name (if applicable)  
• Site Contact  
• Phone Number  
• Email Address  
• Site Address 1  
• Site Address 2  
• City  
• State  
• Zip Code  

Project Details

• Scope of work to be completed  
• Additional Information (if applicable)  

Circuit Information

• Circuit 1 Demarc/Terminal/MPOE Location  
• Circuit 1 LEC ID (if applicable)  
• Circuit 1 Type (if applicable)  
• Circuit 1 Order Number (if applicable)  
• Circuit 1 Delivery Date  
• Circuit 2 Demarc/Terminal/MPOE Location  
• Circuit 2 LEC ID  
• Circuit 2 Type  
• Circuit 2 Order Number  
• Circuit 2 Delivery Date