Form Isp 2-595 - Icn Circuit Move
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2ICN Circuit MOVE
Date of Request: _____/_____/_____
Requested Move Date: _____/_____/_____
Agency Name:________________________________________________________________________________
NCIC ORI: __________________________________ Primary CDC: __________________________________
Circuit ID #: _________________________________ AU Billing #: __________________________________
Requestor’s Name: _______________________________________ Phone #: (
) ______________________
Fax#: (
) __________________________________ E-mail Address: ________________________________
Present Circuit Address: ________________________________________________________________________
City: ____________________________ State: ______ Zip Code: __________ Rm: _________ Flr: _________
Information for new Telco Demarc Location and Router Equipment (Required):
[
] Outside Move
[ ] Inside Move
(provide new address below)
New Circuit Address: _________________________________________________________________________
Telco Demarc
Room #: __________
Floor #: __________
Router
Room #: __________
Floor #: __________
Data Jack Location
Room #: __________
Floor #: __________
Wall: ____________
Will your agency be moving and connecting router to new location
:
[ ] Yes
[ ] No
(check one)
Inside Wiring from Demarc
: [ ] AGENCY
[ ] TELCO
[ ] OTHER VENDOR
(check one)
(charges apply)
Primary Site Contact Name:_________________________________
Phone #: (
) _____________________
Cell #: (
) _________________________
E-mail Address: ________________________________________
Secondary Site Contact Name:________________________________ Phone #: (
) _____________________
Cell #: (
) _________________________
E-mail Address: ________________________________________
Billing Contact Name:________________________________________ FEIN: ___________________________
Phone #: (
) _________________________ E-mail Address: ________________________________________
Comments
: _________________________________________________________
(include restricted site information)
_____________________________________________________________________________________________
Send form to: Mr. Scott Riech
___________________________________________
Illinois State Police, Logistics
Agency Head Signature
th
808 South 8
Street, Suite 200W
Springfield, Illinois 62703
___________________________________________
Fax (217) 524-1068
Agency Head Name (please print)
Phone (217) 524-0089
Scott_Riech@isp.state.il.us
____________________________________________
Agency Head Title (please print)
Order Cannot Be Processed Unless Form is Complete!
R – 052813
ISP 2-592 (6/13)
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