General Information

Your E-Mail address:

Account Number:

Business Name:

Contact Name (First & Last):

Phone Number:

Fax Number:

E-Mail Address:

Sales Person:

Comments:

E-Mail

Comments:

Vanity or Non-Vanity Mail:

Web Mail:

Yes No

Add, Delete or Modify Accounts:

Number of Accounts Sold in This Package:

Domain (rrbiznet.com if non-vanity):

Requested Accounts

Requested Password

Web Hosting

Comments:

Add or Delete:

Add Delete

Domain:

Windows 2000 or Unix Platform:

Package Sold:

Does the Customer Want FrontPage Extensions Enabled (yes or no):

Yes No

New or Additional Persistent IPs

Comments:

Does customer Currently Have a Persistent IP (yes or no):

Yes No

If Yes, Are They Changing Modem Platforms (yes or no):

Yes No

Number of New/Additional IPs Required:

List MAC Address for Each IP Requested:

Remove Persistent IP

Comments:

Reason to Remove IP (change modem platforms, disconnect service):

IP to Be Removed:

DNS Records

Comments:

Domain:

Add Record (A,MX,WWW,CNAME,PTR):

A MX WWW CNAME PTR

Host Name:

Host Name IP:

Modify Record:

A MX WWW CNAME PTR

Host Name:

Host Name IP:

Remove Record:

A MX WWW CNAME PTR

Host Name:

Host Name IP:

New Domain Registration

Comments:

Requested Domain:

Administrative Business Name:

Administrative Business Contact Name:

Administrative Contact Address:

Administrative Contact Phone:

Administrative Contact Fax:

Administrative Contact E-Mail:

Billing Business Name:

Billing Contact Name:

Billing Contact Address:

Billing Contact Phone:

Billing Contact Fax:

Billing Contact E-mail:

Technical Contact:

Domain Transfer

Comments:

Who is the Domain Being Transferred To (TWC NEO, Other Company):

Domain:

Administrative Business Contact Name:

Administrative Contact Address:

Administrative Contact Phone:

Administrative Contact Fax:

Administrative Contact E-Mail:

Billing Business Name:

Billing Contact Name:

Billing Contact Address:

Billing Contact Phone:

Billing Contact Fax:

Billing Contact E-mail:

Technical Contact:

Router/Modem Configuration

Comments:

Tier/Rate Code:

Customer Owned:

Yes No

Number of IPs:

Target Installation Date (preferred one week notice):

Upgrade or New Installation:

If Upgrade, What Other Services Will Be Impacted (mail,web,etc):

Does the Customer Need DHCP/NAT Enabled:

Yes No

If DHCP/NAT enabled, how many devices?

How Many Servers:

What Kind (www,ftp,mail,news,database,file,remote,dns,streaming,other):

How Many Work Stations: