Special Service Circuit Request Form

***** NOTICE: THIS FORM IS CURRENTLY UNAVAILABLE FOR AUTOMATIC SUBMISSION. PLEASE PRINT OUT A COPY AND FAX YOUR REQUEST TO 241-0670. *****

Special Service Circuit Request Form

Use this form to submit your request for any service other than regular POTS (Plain Old Telephone Service) lines or ISDN Telephone service. If you are unable to complete any fields, please contact one of the following managers:

Special Service Manager
Tom Bean
Email: beanjt@oro.doe.gov
Phone: 241-5310
Pager: 222-1603 System Manager
David Holeton
Email: holetondl@oro.doe.gov
Phone: 241-6159
Pager: 222-1607

A meeting and/or field visit may be arranged to better determine the circuit requirements.

SPECIAL NOTE TO Y-12 CUSTOMERS: No external circuits terminating inside Y-12 NSC will be installed until Qwest receives an approval notice from the Y-12 USN manager and the Computing and Telecommunications Security Organization (CTSO).

Please read the Y-12 Configuration Control Measures for Data Communications Services document, print out the Risk Assessment form, complete the form, sign and deliver it to James Gardner (865-574-9391) at 602 Scarboro Road (New Hope Center) room N2.305 or send to mail stop 8227 for approval.

Charge Code Required by Date

NOTE: No order can be processed without a valid charge code.

Requester

Name Email
Telephone

Contact

Name Email
Telephone

Location

From (building/room number)
To (building/room number)

Circuit

Select Circuit Type

Note: See circuit descriptions table for additional information.

IMPORTANT: Please indicate in Service Description
box below whether a 2 or 4 wire circuit is required.

Circuit Descriptions

Glossary

ADSL Service and Pricing

Circuit Quantity or Subscriber Quantity

Service Description/Remarks (describe important details here)

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