VOIP ORDER FORM 970 Reserve Drive, Suite 160, Roseville, CA 95678 Telephone: 530.674.4200 Contact Sales Customer Type: Business Residential CUSTOMER SITE INFORMATION (REQUIRED) Primary Contact: Business Name: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Primary Contact: Business Name: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Billing Email: Billing Phone: TRANSFERRING NUMBERS (NOT NEEDED IF NO TRANSFERS) Phone Number Line Type Voice Fax eFax Voice Fax eFax Voice Fax eFax Voice Fax eFax Add More Numbers VOIP ORDER Qty Service Description Monthly Price Per Qty Business VOIP – Phone Enterprise Polycom Business Phone (includes 1 phone number) $29.99 Business VOIP – ATA Ethernet to Analog Telephone Adapter $24.99 Business VOIP – DID Additional phone number(s) $5.00 Business VOIP – FAX Ethernet to Analog FAX Adapter $24.99 Business VOIP – eFAX Full management portal to send and receive faxes electronically $19.99 Qty Service Description Monthly Price Per Qty Residential VOIP – ATA Ethernet to Analog Telephone Adapter $24.99 Residential VOIP – Number Forwarding Number forwarding only service $10.00 Residential VOIP – DID Additional phone number(s) $5.00 Residential VOIP – FAX Ethernet to Analog FAX Adapter $24.99 Residential 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 (Base Install Fee: $99 + $50 per phone) 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 Add More 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 Individual: Date: I confirm that I am the person named above and that my typed name serves as my electronic signature on this document.
