This form will use your email service to forward to information to us.

This form is used for data collection and will only be used to create Cable & Wireless Contracts for the service.

The completed Contract will be emailed to the Main Contact for signature.

Order Contract Details
  NHSnet Access Agreement Number
  Order Number
  Practice / Site Code
     
Main Contact
This contact will be the main liaison with Cable & Wireless for the order
  First name
  Last name
  Organisation Name
  email
  Telephone number
  Fax number
  Registered Address
  Post Code
     
Installation Address
  Site contact - First name (if different from above)
  Site contact - Last name (if different from above)
  Organisation Name (if different from above)
  Site contact - email (if different from above)
  Site contact - Telephone number (if different from above)
  Site contact - Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
     
Billing Contact
  First name (if different from above)
  Last name (if different from above)
  Organisation Name (if different from above)
  email (if different from above)
  Telephone number (if different from above)
  Fax number (if different from above)
  Address (if different from above)
  Post Code (if different from above)
     
NHS IA IP Addressing
  Confirm that you have read and comply with the new NHS IA IP Addressing Policy. Click here for details.
  Confirm you have completed the NHS IA IP space request form. Click here for details.
  State which of the NHS IA IP addressing scenarios is to be implemented. Click here for details.
  State the number of IP addresses you require
  State the user base number within your organisation
  Other IP Addressing information
     
NHSnet Installation Details
  Network Termination Point (NTP) Location - all details are required
Building
Department
Floor
Room
Location within room
  NTP Mounting
  Do you have an existing NHSnet connection from BT
  Site access and security arrangements
  General Comments