Company Information
Company Name
Department
Address 1
Address 2
City / Town
St/Prov
Country
Phone Numbers
Office
Fax
Toll-Free
Email 1
Email 2
Email to send rates
Email to send invoices
Website
Technical Contact Information
Mr. / Ms.	Mr Ms
First Name
Last Name
Position
Department
Address 1
Address 2
City / Town
St / Prov
Zip / Postal
Country
Email:
Instant Messaging (IM)
Phone Numbers
Office
Fax
Direct
Toll-Free
Mobile
Your Equipment Information
Protocol	SIP H323
Gateway or GateKeeper	Gateway Gatekeeper
IP Address of Gatekeeper
IP Address of Gateway
Gatekeeper Manufacturer
Gatekeeper Model
Gatekeeper IOS ver
Gateway Manufacturer
Gateway Model
Gateway IOS ver
IP Backbone Provider Name
Size of Backbone in Megabits
Carrier CODEC	G723 G729
Requested CODEC	G723 G729
Billing Software
Country City / Type Ports Price (USD) Billing Increment Terms 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30 1,1 6,6 30,6 60,60 Pre-Pay VoIP Escrow EMS Escrow 7 NET 30