Network Connection Service Request Form

1. Institution Name

Start typing... 1. Institution Name

2. Member site A for Service:

Address Line 1

Address Line 2

City/Town

Province

Postal Code

3. Site B for Connection:

Start typing... 3. Site B for Connection:

Member/Client Connection Site

4. Network Service Requests:

Start typing... 4. Network Service Requests:

Other Network Service Request

5. Requested Connection Speed (in Mbps or Gbps)

6. Requested Physical Connection Type (Select all that apply):

Dark Fibre

Point-to-Point Ethernet

Other (Please specify)

Other Physical Connection Type

7. Requested Service Production Date:

8. Commitment for Service (Years)

Start typing... 8. Commitment for Service (Years)

9. Additional Network Services Required as part of the Project:

10. Additional BCNET Services associated with the request:

11. Additional Comments:

12. Budget Envelope for Project:

13. Funding Source (Select all that apply):

Self-Funded

Ministry of Advanced Education & Skills Training

Other (Please specify)

Other Funding Source

14. Confirmed Funding:

Yes

No

No Confirmed Funding

15. Service Request Submitted By:

Name:

Role:

Email Address:

Telephone Number:

16. Service Request Authorized By (Name and Role):

Name;

Role:

Email Address:

Telephone Number:

17. Primary Contact for this Project:

Name:

Role:

Email Address:

Telephone Number:

18. Verify Contact Information

Your name

Your email address

Your phone number

Verification Code

Network Connection Service Request Form

Other Fields