VOIP Order Form This form is used to sell our VOIP Services. CUSTOMER SITE INFORMATION (REQUIRED)Primary ContactBusiness NameAddressCityStateZipContact Phone (Primary)Contact Phone (Secondary)Contact EmailBILLING INFORMATION (IF DIFFERENT FROM CUSTOMER SITE INFORMATION)Billing AddressCityStateZipBilling EmailBilling PhoneTRANSFERRING NUMBERS (IF TRANSFERRING)NumberNumber Type Voice FAX eFAX VOIP ORDER FORM 970 Reserve Drive, Suite 160, Roseville, CA 95678 Telephone: 530.674.4200 CUSTOMER SITE INFORMATION (REQUIRED) Primary Contact: Business Name: Address: City: State: Zip: Contact Phone (Primary): Contact Phone (Secondary): Contact Email: BILLING INFORMATION (IF DIFFERENT FROM CUSTOMER SITE INFORMATION) Billing information is the same as the above section Address: City: State: Zip: Billing Email: Billing Phone: TRANSFERRING NUMBERS (NOT NEEDED IF NO TRANSFERS) VOIP ORDER Qty Service Description Monthly Price Per Qty Business VOIP – Phone Enterprise Polycom Business Phone (includes 1 phone number) $29.99 Business VOIP – DID Additional phone number(s) $5.00 Business VOIP – ATA Ethernet to Analog Telephone Adapter $24.99 Business VOIP – FAX Ethernet to Analog FAX Adapter $24.99 Business VOIP – eFAX Full management portal to send and receive faxes electronically $19.99 ORDER TOTAL Total Order MRC Total Order NRC MRC = Monthly Recurring Costs (Service Price) NRC = Non-Recurring Costs (Install or Setup Fees) USER INFORMATION Below is the user information per phone. If a phone is not going to be designated to a specific person, then put in the name of the area it will be located for the first name. Example: Shop or Warehouse. All information listed below may be changed as needed. EXT FIRST NAME LAST NAME Email Address Customer agrees to pay the Total Order MRC and Total Order NRC, the amounts of which in all instances are exclusive of taxes, surcharges and fees to be imposed by Succeed.net including, but not limited to, applicable federal, state, local use, excise, sales, or privilege taxes, duties or similar liabilities either shown as Miscellaneous Charges or imposed by operation of law. If there are any discrepancies between the Total Order MRC and Total Order NRC shown above and charges appearing elsewhere in this Agreement, above totals shall be controlling. The Total Order MRC and Total Order NRC apply only to those products listed in this order, the amounts indicated do not supersede any outstanding or recurring invoiced amounts on the Clients account and are in addition to any other services and products currently billed to the customer. Authorized Signature: Date: Printed Name:
