1: Date:

2: Order Type: newdisconnectchange

3a: 800 Number (change or disconect orders only)

3b: 800 Coordinated conversion? yesno

4: Service Request Date:

5: Identify the Primary User of the Service (the person who will be responsible for the use of the service; i.e.,Telecommunications manager, IRM manager, or actual user):

Name:

Title:

Phone:

Please supply complete CBS Accounting information
or CBS reference number (FCFGJ1234):

6a: FTS2000 telephone number the 800 service will route to:

6b: Number of phones 800 number will be routed to:

7: Published in WATS National 800 Directory? (indicate Yes if you want this 800 number published in the WATS National 800 Directory

yesno

8: Local Phone Service Information:

Agency Name:

Address:

9: Local Government Contact (the local government contact who can verify that 800 service has been received):

Name:

Phone:

10. Alternate Local Government Contact:

Name:

Phone:

11. Monthly Usage Minutes (estimate the total number of minutes of usage per month for this service): NOTE: If this order is a disconnect indicate anticipated decrease in monthly usage.

12. Pre-sale information:

Day of week busy hour occurs (e.g. Monday):

Expected busy hour and time zone:

Number of call attempts during busy hour:

Seasonal volume (month and attempts during busy hour, e.g. Nov - 850 calls ):

Percent of increase during busy hour after 6 months and 12 months:

13. Remarks:

STATEMENT OF OBLIGATION BY NOAA BUDGET OFFICIAL:

As the NOAA approving official authorized to expend funds for FTS2001 orders, I hereby obligate $ for FY and thereafter until further notice for FTS2001 products and services. Not to exceed $ (per FY)

Authorized by:

NOAA Approving Officer:

Approving Officer's Title:

Approving Officer's Phone Number:

Approving Officer's Address:

Date Submitted:

Approving Officer's E-Mail Address:

Press to your 800 Service Request

Press to clear the 800 Request Form for another order

Submission of this information is voluntary and will only be used for the stated purpose.