ALL FIELDS ARE REQUIRED

Email of Service Rep Submitting Form:

Customers Name: 

Customers Account Number: 

Customers Phone Number: 

Customers E-Mail Address: 

Level of Service: Luminous Residential Luminous Business Star Residential DSL Star Business DSL Star Residential Fiber Star Dedicated (T1, Frame, Fiber) StarVision Business Cable StarVision SOHO Cable InterStar Business Wireless InterStar SOHO Wireless InterStar Business ADSL InterStar SOHO ADSL InterStar ISDN InterStar Dedicated (Wireless, Fiber)

Briefly describe your network configuration, including the number of hosts.  EXAMPLE:  I've got a router, 2 PCs and a security DVR.

Specify the make and model of Router or PC that is bordering the Star/StarVision/InterStar network.  (What is plugged into the modem)

 EXAMPLE: Linksys WRT54G or Dell Server or Security DVR 

How many static IP addresses will you require?  1 2 3 4 5 6 7 8 9 10  

Choose the purpose of each host that will be using a dedicated IP: Security System Remote VPN Remote Management Other   If Other please specify:

If InterStar hosts your DirectoryNameService (anyone.intrstar.net) , will you require DNS modifications (Usually answered NO by 99% of customers) Yes No

If DNS Modifications are needed, what are they?

Will you require on-site assistance for setup/configuration? Yes No

Who should we contact with technical questions regarding this request?  Please list their Name, Number and E-Mail address

Name:

Phone:

Email: