Service Request Form

1. Company Name(required)
2. Type of company Select... Limited Liability PLC Sole Proprietorship Enterprise Other
3. Registered Business Address(required)
4. Operational Office Address (if different from above)
5. Contact Person
6. Designation
7. Telephone
8. Email Address(valid email required)
9. Website
10. Date of Request
11. Type of Service Required Select... Sales Services VPN/MPLS (IP & ETHERNET) Services Int'l Private Leased Circuit (IPLC) Domestic Leased Circuit (DLC) Last Mile/Colocation Services VOIP Termination Services VOIP Subscription Services
12. Why you need the service? Select... For Private Use For own business use As a Telecoms Service Provider As a reseller partner to Phase3 Telecom As a carrier's agent
13. Capacity Required Select... 1 E1(i.e. 2Mbps) 3 E1(i.e.6Mbps) DS-3(i.e. 45Mbps) STM-1(155 Mbps) 4 X STM-1(620Mbps) Above 4XSTM-1
14. Route/Location where capacity is Required
15. Is Last Mile Required?
16. Yes No
17. Preferred Last Mile option * Radio Fiber Wimax Others (Please state clearly below)
18. Address where capacity is required (If Different From Operational Address Above)
19. State (If applying from inside Nigeria) Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu FCT Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara
20. Country (If applying from outside Nigeria)

 

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*Last Mile Charges Are Separate from the Cost of Capacity Required and Will Be Negotiated Differently Depending On The Preferred Option and Distance To Be Covered