Telephone Order Service Request Form (TO-5)

Date: Page: TO-5 Telephone Order Service Request Office of Information Technology Services Telephone: (919)-754-6700 Requested Due Date: Telecommunications Services Fax to: (919)-850-2828

4110 Mail Service Center ITS Home Page Web Address: TO-5 and TO-5-A Raleigh, North Carolina 27699-4110 http://www.its.state.nc.us Instructions sheet Service Request Number (IUO): Repairs 1-800-722-3946

Please answer all questions below to expedite processing of this order. Please print or type.

Requestor Name: Requestor Telephone Number: ( ) - EXT:

Requestor E-mail: Requestor Fax Number: ( ) -

Name (Requested for): Telephone Number: ( ) - EXT:

16 digit Department Code (Mandatory): Bill -To Telephone Number (Mandatory): Floor (Location): Room (Location):

( ) - Federal ID: Department Name: Division: 56-6001087 Street Address: (Work Location): City / Town: Zip Code: County: Northampton County Old Street Address (Only for a move): City / Town: Zip Code: County:

Site Contact Name: Site Contact Telephone Number: ( ) - EXT:

Site Contact E-mail: Site Contact Fax Number: ( ) - Room Number:

Type of Service: Equipment Type: Model Number: System: Line Type:

Move Auth Code Single Line set ______Centrex Centrex Line Add Long Distance Cortelco ______Key System Fax Line Change Toll Free (1-800) Avaya ______PBX ISDN Meridian ______Disconnect Voice Mail Other______Modem Line Norstar / Sprint Meridian Nortel ______Inside wiring required Other ______Meridian Voice Line Meridian ______Toshiba Other______

Other ______Describe the Service Request. Attach an addendum if required. Use only 1 installation site address per TO-5.

______Principal's Signature Date

Disclosure Statement: Recipients of N.C. State calling cards are responsible for the use of the cards that have been issued to them.

Budget Officer’s Signature (Mandatory): SOF Telephone: ( ) - Date: This TO-5 Form supersedes all other versions. TO-5 Version (Date) 2/1/06.