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IPitomy Router Services Order Form
Technical Contact Name
Dealer/Agent Email Address
Dealer/Agent Phone Number
Will the router be used on premised based system or Cloud?
Customer Company Name
Customer City and State
Customer Contact Name
Customer Contact Email For Billing
Customer Phone Number
Enter customer's current router make and model
Enter customer's current internal IP scheme.
Static IPs used on LAN
Enter customer's public IP address or addresses.
Enter customer's public subnet mask.
Enter customer's public gateway address.
vMPLS Info- Please enter names of the sites that you need to be connected together. Note: There is an extra monthly fee for this service. Be sure to include that on this order.
Enter the local static IP of the PBX.
Enter Port Forwarding Request (Port/Port Range, Protocol TCP/UDP or Both, IP Address
Upload file if needed. Screenshots, etc.
Additional comments or requests.
Standard Monitoring Service is required. Standard Monitored Service MRC ($25.00) Includes Firewall and software updates, Basic Diagnostics, VoIP Traffic Shaping, Emailed Alerts
Standard Monitored Service
Additional Advanced Optional Monitoring Services:
vMPLS separate add-on per site MRC $30.00
Content Filtering separate add-on MRC $10.00
Cyber Package PCI/HIPPA Reporting, PEN Testing add-on MRC $60.00
Dual Wan Failover separate add-on MRC $10.00
Dealer Monthly Monitoring on NFR MRC ($15.00) *Dealers only