Telephone Order Service Request Form (TO-5)
-53975-18605500TO-5 Telephone Order Service Request Date: FORMTEXT ?????NC Department of Information Technology Service DeliveryPO Box 17209; Raleigh, North Carolina 27619-7209DIT Home Page Web Address: Service Desk:(919)-754-6000;1-800-722-3946Upload this completed form to the DIT Service Now Portal: ***Sign into the Service Now Portal using NCID credentials & attach this form to your request.Requested Due Date: FORMTEXT Service Request Number (IUO): FORMTEXT ?????Information requested below is REQUIRED in order to expedite processing.Requestor Name (mandatory): FORMTEXT ?????Requestor Telephone Number (mandatory): ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Requestor E-mail (mandatory): FORMTEXT ?????Requestor Fax Number: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Name (Requested for): FORMTEXT ????? Telephone Number: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????16 digit Department Code for Bill To Telephone Number (mandatory): FORMTEXT ???? FORMTEXT ???? FORMTEXT ???? FORMTEXT ????Bill To Telephone Number (mandatory):( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Floor (Location): FORMTEXT ?????Room (Location): FORMTEXT ?????Federal ID: FORMTEXT ?????Department Name: FORMTEXT ?????Division: FORMTEXT ?????Street Address: (Work Location): FORMTEXT ?????City / Town: FORMTEXT ?????Zip Code: FORMTEXT ?????County: FORMTEXT ?????Old Street Address (Only for a move): FORMTEXT ?????City / Town: FORMTEXT ?????Zip Code: FORMTEXT ?????County: FORMTEXT ?????Site Contact Name (mandatory): FORMTEXT ?????Site Contact Telephone Number (mandatory): ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Site Contact Name (mandatory): FORMTEXT ?????Site Contact Telephone Number (mandatory): ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Site Contact E-mail: FORMTEXT ?????Site Contact Fax Number: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Room Number: FORMTEXT ?????Type of Service:Phone Type:Model Number:System:Line Type: FORMCHECKBOX Move FORMCHECKBOX Auth Code FORMCHECKBOX Single Line set________ FORMTEXT ????? FORMCHECKBOX Centrex FORMCHECKBOX Centrex Line FORMCHECKBOX Add FORMCHECKBOX International Long Distance FORMCHECKBOX Avaya________ FORMTEXT ????? FORMCHECKBOX Key System FORMCHECKBOX Fax Line FORMCHECKBOX Change FORMCHECKBOX Toll Free (1-800) FORMCHECKBOX Nortel/Meridian________ FORMTEXT ????? FORMCHECKBOX PBX FORMCHECKBOX ISDN PRI FORMCHECKBOX Disconnect FORMCHECKBOX Integrated Voice Messaging Service (IVMS) [see page 2 for provisioning details] FORMCHECKBOX Nortel/Norstar________ FORMTEXT ????? FORMCHECKBOX ITS EIPT FORMCHECKBOX Modem Line FORMCHECKBOX Inside wiring required FORMCHECKBOX Auto Attendant FORMCHECKBOX ToshibaMeridianMeridian________ FORMTEXT ????? FORMCHECKBOX ITS Mngd PBX FORMCHECKBOX Voice Line FORMCHECKBOX Other_________ FORMCHECKBOX Other________ FORMTEXT ????? FORMCHECKBOX ITS IVR/Call Ctr FORMCHECKBOX Other_______ FORMCHECKBOX Other __________ FORMTEXT ????? FORMCHECKBOX Other_________Describe the Service Request. Attach an addendum if required. Use only 1 installation site address per TO-5. FORMTEXT ?????Budget Officer’s Signature (mandatory): SOF FORMCHECKBOX Telephone: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ???? Date: FORMTEXT ?????0000Integrated Voice Messaging Service (IVMS)The Integrated Voice Messaging Service provides users with an assortment of voice mail tools in one solution that enhances communications and productivity.General IVMS InformationIVMS Mailbox User Name: FORMTEXT ?????IVMS Mailbox “0” Out Number (if applicable): FORMTEXT ???? - FORMTEXT ???? - FORMTEXT ????Service Offering OptionsChoose which service offering you prefer; Basic FORMCHECKBOX Basic without Integrated Fax FORMCHECKBOX Basic with Integrated Fax, please provide e-mail address for fax delivery. FORMTEXT ?????Advanced FORMCHECKBOX AdvancedCheck all that apply; FORMCHECKBOX Integrated Fax, please provide e-mail address for fax delivery. FORMTEXT ????? FORMCHECKBOX Reach MeList up to three numbers to be where you can be “reached”.1st - FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ????2nd - FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ????3rd - FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ???? FORMCHECKBOX Notify MeWhere would you like to be “notified” you have a voice mail?E-mail address: FORMTEXT ?????Text Message: FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ????Pager: FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ????A phone call to: FORMTEXT ??? - FORMTEXT ??? - FORMTEXT ????CustomFor custom service offering design please call 919-754-6000 and one of our analysts will be glad to assist you. ................
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