Submitted by:
Name
Phone Number
Email Address
Additional Email Address
List additional customer contact emails to carbon copy on the form submission confirmation.
Frontier Account Team
Select your Frontier Account Team Member(s) to receive a copy of your submission:
Bart.Greenwell@FTR.com
Brenda.Cuevas@FTR.COM
Brenda.Green@FTR.com
Brian.McPherson@FTR.com
Denise.Zentler@FTR.com
Deven.Barker@FTR.com
Eric.Usilton@FTR.com
Jana.Brooks@FTR.com
Jean.Beurkens@FTR.com
J.R.Marshall@FTR.com
Marie.Mosqueda@FTR.com
Noel.Geyer@FTR.com
Pamela.Oller@FTR.com
Robert.Lucido@FTR.com
Shari.Lee@FTR.com
Tricia.Warriner@FTR.com
Will.Fowler@FTR.com
Customer Information (End User)
Company Name
Street Address
City
State
Zip
Phone Number
Root Domain Name
PON
Is this an existing circuit in service?
Yes
No
Existing EVC Circuit ID
Customer Point-of-Contact Information (Carrier Customer)
Carrier Company
Carrier Contact Name
Carrier Contact Phone Number
Carrier Contact Email Address
Renumbering Information
Are you renumbering?
Yes
No
Are you renumbering your old?
Yes
No
List ALL Blocks to be Renumbered
Previous provider IP's must be returned after renumbering.
Timeframe Required for Renumbering
Name Server Information for Reverse DNS
If you are providing Name Server (NS) info then both a primary and secondary NS must be present.
Primary NS Name
Secondary NS Name
Requested Netblock
Number of IPs Upon Initial Request
Forecasted Number of IPs in One Year
IP Address Type
IPv4
IPv6
IPv4 / IPv6 (Dual Stack)
IPv4 CIDR Block Requested
/27
/26
/25
/24
IPv6 CIDR Block Requested
/64
/48
Are you IPv6 Capable?
Yes
No
What timeframe will you be ready to deploy IPv6?*
Current IP Address Usage
Provide the numbers detailing your current network to justify the requested IP Block.
Fields are required. Zero may be entered as a valid entry, however, total of all IP Address Usage fields must justify requested block size.
VPN QTY
Firewall QTY
Web Hosting QTY
Virtual Gaming/Training QTY
FLAT LAN Connection QTY
Computer QTY
Will NAT be utilized?
Yes
No
If No, explain why:
Servers QTY
Servers Vendor and Model Numbers
Provide a list of address space already in use and whether you will be renumbering out of that address space or not. If you are a Wireless provider include network IP plan down to the Private space pools. Pinpoint the Public to Private ratio.
Address Space
Wireless Network IP Plan
Explanation of Network Architecture
Provide detail explanation of your network architecture and how you will be using it.
Network Architecture Explanation
Provide any additional details and provide
quantity that will use a global/public IP address that was not yet accounted for above.
Miscellaneous Details
ALERT: A network diagram will be required if requesting a CIDR /26, /25 or /24. Please see direction provided on confirmation email received after form submission.
List All Domains