1. Order Number (Previously Obtained From Integra Customer Care):

1. Company Name:
2. Integra Sales or Customer Care Representative:
3. Customer Account Number:
4. Your Integra Market: Select Your AreaArizonaCalifornia - SacramentoCalifornia - Santa RosaColoradoIdahoMinnesota - Prior Lake AreaMinnesota - St. Cloud & Northern MNMinnesota - Twin Cities Metro AreaMontanaNevada - Las VegasNevada - RenoNorth DakotaOregon & SW WashingtonUtahWashington

1. Name:
2. Phone:
3. Email:
4. Street Address:
5. City:
6. State: SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
7. Zip Code:

1. Is your technical contact the same as your primary contact? Yes No
2. 1. Technical Contact Name or Company:
   2. Technical Contact Phone Number:
   3. Technical Contact Email:
   4. Technical Contact Street Address:
   5. City:
   6. State: SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
   7. Zip code:

1. Number of IP Addresses Requested: Select 32 - 2 IPs (1 usable IP) 30 - 4 IPs (2 usable IPs) 29 - 8 IPs (6 usable IPs) 28 - 16 IPs (14 usable IPs) 27 - 32 IPs (30 usable IPs) 26 - 64 IPs (62 usable IPs) 25 - 128 IPs (126 usable IPs) 24 - 1 Class C (254 usable IPs) 23 - 2 Class Cs (508 usable IPs) 22 - 4 Class Cs (1016 usable IPs) 21 - 8 Class Cs (2032 usable IPs)
2. Please indicate how you plan to use the IP addresses that you are requesting:
3. Number of Routers:
4. Number of Servers:
5. Number of Workstations:
6. Number of Dial-Ups:
7. Number of Web Hosts:
8. Other Use (Please describe):
9. Total:
10. Please describe your planned usage of new IP addresses and any special requests:

1. Do you require IPv6 Addresses? Yes No

The default allocation is a single /48

IPv6 Planned Usage

1. Are you an Internet Service Provider? Yes No
2. 1. Will you assign IP addresses to your customers? Yes No
   2. Do you provide dial-up Internet access? Yes No
      
      
3. Do you currently have IP addresses issued to you by Integra Telecom? Yes No
4. 1. Please list the current range of IP addresses that Integra has assigned to you:
   2. Please provide the number of Integra IP addresses that are currently being used for each of the following:
   3. Number of Routers:
   4. Number of Servers:
   5. Number of Workstations:
   6. Number of Dial-Ups:
   7. Number of Web Hosts:
   8. Other Use (Please describe):
   9. Total:
5. Do you currently have IP addresses from another Internet service provider? Yes No
6. 1. Will you be returning the IP addresses to that service provider? Yes No
   2. Please list all IP address blocks from other providers:
7. Please check this box to indicate that you understand and acknowledge that all IP address space assigned to you by Integra Telecom is non-portable and will be released back to Integra if you discontinue Integra's Internet service. I understand and acknowledge.

2. Click 'Submit" to send your request