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Master Contract Id 338588 Verizon Service Order Form

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Master Contract Id 338588 Verizon Service Order Form Commonwealth of Massachusetts ITT46 Network Services Master Contract Id 338588 Verizon Service Order Form IMPORTANT: This form is to be used by Eligible Entities to order services or products from Verizon (excluding products/services of Verizon Wireless) under Commonwealth Of Massachusetts Statewide Contract No. ITT46, also known as Verizon Contract No. 338588 (the “Agreement”). By signing below, Customer understands and agrees that the rates, charges, terms and conditions of the Agreement, which includes all documents attached to or incorporated in such Agreement, shall apply to the service(s) and/or products requested and provided under this Order Form. A copy of the Agreement is on file with the Commonwealth Operational Service Division and is available from Verizon account representative upon request. Customer Name: Town of Sample (“Customer”) By: John Doe 2/6/2013 Authorized Customer Signature * Date Print Name/Title: John Doe, IT Director * If signature is other than the ordering Eligible Entity, a letter of authorization is required from the ordering Eligible Entity. Please complete un-shaded areas. For assistance contact: [email protected] Contact Information for Customer Submitting Request Name: Priscilla Downs Phone: xxx-xxx-xxxx Email: [email protected] Requested Due Date: 6/1/2013 Action Requested: New X Change Add Disconnect Upgrade Cancel (Insert X in Desired Box) Account Number Information: 617-xxx-xxxx [Located on Existing VzT Bill or indicate NEW] Y1234567 [Located on Existing VzB Bill or indicate NEW] Summary Bill Information: 617-xxx-xxxx [Applicable for VzT Only] Service Type & Quantity: * [Insert Product/Service from Cost Tables and Quantity Requested] * Obtain accurate Product Name as listed in Cost Table. * Rates and charges will be billed in accordance with applicable Cost Tables in effect during the term of the Agreement. * If you are ordering Centrex, PRI or Analog Business Line, you must select an option for Verizon Local Toll Usage (Outgoing Intra-LATA Toll Services). Select either ITT46 Local Usage Rate or Existing Verizon Usage Plan (specify Existing Usage Plan if applic.) ITT46 Local Usage Rate Existing Verizon Usage Plan Specify Existing Verizon Usage Plan: * If Long Distance is required, please select VzB LD or Other (specify Other Carrier if applic.) VzB LD Other Specify Other Carrier: Billing & Contact Information Bill Line 1: Town of Sample Bill Line 2: ITT46 - Attn Priscilla Downs (Keep ITT46 as Prefix to BN2) Street Address: 220 Main Street City: Sample State: MA Zip: 000000 Billing Contact Phone Number: xxx-xxx-xxxx Billing Contact Email: [email protected] Service/Installation Information Install/Service Location: Location #1: [ Address ] 440 Main Street [ City ] Sample [ State ] MA [ Zip ] 000000 Note: Add Locations as needed with a space in-between and a location number designation. On-Site Telephone Number: xxx-xxx-xxxx Floor/Room: 2nd Floor / Room 201 Telco Demarc/Floor No: 1st Floor / Room 101 Primary Technical Name: Jose Hernandez Primary Technical Phone: xxx-xxx-xxxx Primary Technical Email: [email protected] Secondary Technical Name: N/A Secondary Technical Phone: Secondary Technical Email: Access Arrangements and/or Check in at reception and request that primary contact be notified. Additional Comments: Primary contact will provide site access. Special Notes: 1. Customer authorizes Verizon to provide the following blocks: International Block, 900/976 Block, Cramming Block, 3rd Party Billing Block. 2. Verizon may require additional contract documentation to be signed by Customer (e.g. Statements of Work, Preferred Carrier Freeze Form, etc.). 3. Customer MUST provide ST2 and ST5 per Department of Revenue if Tax Exemption applies. 4. MHEC contract MC12-J04 - Private/Public College and/or University in Massachusetts identified as an Eligible Entity under the State Contract ITT46 on comm-pass.com. END OF ITT46 CUSTOMER ORDER FORM FOR VERIZON PERSONNEL USE ONLY ITT46 CONTRACT COVER PAGE FOR ALL CONTRACT VIEWER SUBMISSIONS ALL ORDERS MUST BE MAPPED TO MASTER CONTRACT ID - 338588 Verizon Sales Representative: (Email Address Only) Account Nasp ID: (Mandatory for fMCI Orders) Account SubNasp ID: (Parent Nasp + “0046”) Required to ensure ITT46 Pricing Verizon New England Select the Verizon Affiliate: VNIC (Mandatory for Routing) MCI Communications Cybertrust/Terremark Verizon Additional Comments: Select if Ordering a Bundled 2 Bundle Option - MPLS and IP Trunking Discount Option: 3 Bundle Option - MPLS, IP Trunking and Toll Free NOTE TO VERIZON SALES REPRESENTATIVE: USE THIS PAGE AS PAGE ONE WHEN SUBMITTING TO CONTRACT VIEWER. .
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