FTS2001 ANI Service Request Form

1. Date:

2: Order Type: newdisconnect

3: Service Request Date:

4: 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):

5: Local Phone Service Information (enter the billing name, billing telephone number, and address as shown on the commercial telephone bill of the location for which ANI service is being ordered):

Billing Name:

Address:

Billing Phone Number:

6: ANI Service for ALL Stations? (indicate yes or no if you want all stations at this location to have ANI service)

YESNO

7: PSN Phone (list the Public Switched Network phone numbers at the site you wish to order ANI service for, e.g., 202-555-5257):

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

Name:

Phone:

9. Alternate Local Government Contact:

Name:

Phone:

10. Agency Address (give the physical address where the stations are located):

Street:

Building: Floor: Room:

City: State: Zip:

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. 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 ANI Request

Press to clear the ANI Form for another order

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