## Request Form

### Company Information

| Company Name: |  |
| --- | --- |
| PO or Reference No.: |  |

### Company Billing Address

| Street Address 1: |  |  |  |
| --- | --- | --- | --- |
| Street Address 2: |  |  |  |
| City: |  | State/Province/Region: |  |
| Country: |  | Postal/Zip Code: |  |

### Company Point of Contact

| Name: |  | Email: |  |
| --- | --- | --- | --- |
| Phone: |  | Mobile: |  |

### Request Details

#### Secondary Wireless Card

##### Options

- VM Telesploit Server

|  |  |  |
| --- | --- | --- |

- No Windows VM  
- Win 10 Pro (Plain VM)

### Request Special Instructions

* * *

### Client Deployment Information

#### Delivery Address

| Street Address 1: |  |  |  |
| --- | --- | --- | --- |
| Street Address 2: |  |  |  |
| City: |  | State/Province/Region: |  |
| Country: |  | Postal/Zip Code: |  |

#### Client Point of Contact

| Name: | Email: |
| --- | --- |
| Phone: | Mobile: |

#### Client Technical Information

- IP Configuration: DHCP Static

##### Static IP Address Details (if applicable)

| IP Address: |  | Netmask/CIDR: |  | Default Gateway: |  |
| --- | --- | --- | --- | --- | --- |
| DNS 1: |  | DNS 2: |  | DNS 3: |  |

#### Outbound Connection

- Other (specify below)

##### Other outbound connection information

##### Outbound Proxy

- Proxy IP Address:  
- Proxy Port:  
- None (default)
- Simple  
- Basic Authentication (account required)
- NTLM (account required)

### Deployment Special Instruction

* * *

### Key Access

- **User 1**  
  Email:  
  Name:  
  Phone:  
  Mobile:

#### Server and Collaboration Access

- Collaboration Only  
- Add/Remove Users  
- SSH Public Key (OpenSSH):

- **User 2**  
  Name:  
  Email:  
  Phone:  
  Mobile:

#### Server and Collaboration Access

- Collaboration Only  
- SSH Public Key (OpenSSH):  
- Add/Remove Users

- **User 3**  
  Name:  
  Email:  
  Phone:  
  Mobile:

#### Server and Collaboration Access

- Collaboration Only  
- Add/Remove Users  
- SSH Public Key (OpenSSH):

- **User 4**  
  Name:  
  Email:  
  Phone:  
  Mobile:

#### Server and Collaboration Access

- Collaboration Only  
- Add/Remove Users  
- SSH Public Key (OpenSSH):

- **User 5**  
  Email:  
  Name:  
  Phone:

#### Server and Collaboration Access

- **User 6**  
  Server and Collaboration Access
  Mobile:  
  Add/Remove Users

##### Notifications

- SSH Public Key (OpenSSH):  
- SSH Public Key (OpenSSH):