EZNET Total Access 848 4th Ave. 3rd Floor Huntington, WV 25701 Email: info@ezwv.com Fax: (304) 525-3772 Date:___________________ NAME:_______________________________________________________________________ COMPANY NAME:_______________________________________________________________ ADDRESS:____________________________________________________________________ CITY:_______________________________________________________________________ ZIP CODE:______________________________ STATE:_____________________________ PHONE:_________________________________ EMAIL:_____________________________ FAX:___________________________________ What is the best way to contact you? ___ Phone ___Email What is the nature of your business? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Is your company currently using the Internet? ___ yes ___no Who is your current Internet Provider? ____________________________________________________________________________ How many dial-up connections do you have? ____________________________________________________________________________ Do you have a dedicated high speed connection? ___ yes ___no What type of access are you using? ___ ISDN ___ Wireless ___ Frame Relay ___ Full T1 ___ Other What type of access are you interested in? ___ ISDN ___ Wireless ___ Frame Relay ___ Full T1 ___ Other What type of CSU/DSU are you using? Make:_________________________________ Model:_____________________________ What type of Router are you using? Make:_________________________________ Model:_____________________________ Do you have a LAN? ___ yes ___no What type of Network Operating System are you using? ___ Novel ___ Lantistic ___ Windows ___ Unix ___ NT ___ Other Is your LAN TCP/IP compliant? ___ yes ___no Do you have a Domain Name? If yes, what is the address? ____________________________________________________________________________ Do you have a Web Site? ___ yes ___no Where is it currently being hosted? ____________________________________________________________________________ Who would be involved in the decision making process? ____________________________________________________________________________ Do you have a budget for this site/project? ___ yes ___no What is your time-frame/deadline for this project? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please list any additional information that you feel may be useful in assessing your needs or concerns you have about this project, etc. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________