Form Isp 2-590 - Icn Circuit Order
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3ICN Circuit ORDER
Date of Request: _____/_____/_____
Requested Installation Date: _____/_____/_____
Agency Name: ____________________________________________________________________________
NCIC ORI: __________________________________ Primary CDC: _______________________________
Requestor’s Name: _____________________________ Phone #: (
) ______________________________
Fax #: (
) __________________________________ E-mail Address: _____________________________
Circuit Street Address: ______________________________________________________________________
City: _______________________________________
State: ______ Zip Code: _____________________
Purpose for Circuit Installation (mark all that apply):
[ ] Livescan
[ ] LEADS 2000
[ ] LEADS - Interface Agency, LEADS Interface Vendor Name: _________________________________
Information for Telco Demarc Location and Router Equipment (Required):
Telco Demarc
Room #: __________
Floor #: __________
Router
Room #: __________
Floor #: __________
Data Jack Location
Room #: __________
Floor #: __________
Wall: ____________
Inside Wiring from Demarc (check one): [ ]
[ ]
[ ]
AGENCY
TELCO
OTHER VENDOR
(charges apply)
Primary Site Contact Name:__________________________________ Phone #: (
) _________________
Cell #: (
) _________________________
E-mail Address: ____________________________________
Secondary Site Contact Name:________________________________ Phone #: (
) _________________
Cell #: (
) _________________________
E-mail Address: ____________________________________
Comments
: ___________________________________________________
(including any restricted site information)
_________________________________________________________________________________________
Send form to: Mr. Scott Riech
Billing Contact Name: _________________________
Illinois State Police, Logistics
th
808 South 8
Street, Suite 200W
FEIN: ______________________________________
Springfield, Illinois 62703
Street Address: ______________________________
City, State, Zip: ___________ Phone: (
) ________
Fax: (217) 5248-1068
AU #: _____________________________________
Phone: (217) 524-0089
Scott_Riech@isp.state.il.us
___________________________________________
Agency Head Signature
___________________________________________
Agency Head Name & Title (please print)
ISP 2-590 (6/13)
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Orders Cannot Be Processed Unless Form is Complete!
R - 052813
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