IP Address Request Form - BTCL

Bangladesh Telecommunications Company LimitedIP Address Request Form[A] Administration/ Billing ContactFull Name :Title/Occupation :Organization :Address :City and Post Code :Email Address :Phone and Fax no.[B] Technical ContactFull Name :Title/Occupation :Organization :Address :City and Post Code :Email Address :Phone and Fax no.Contact Information[A] IP Address Requirement:Network Name [within 25alphanumeric uppercase character]:Name of Organization :Address :Technical InformationNo. of IP address Required :Use the IP address : Own network Sub-allocate to end user

[B] Future Plan:Size of Planned subnet [Example: 0.0.0.0/28] :Deploy Now [Example: /29] :Deploy within 6 months [Example: /29] :Deploy within 1 year [Example: /28] :Detail description of subnet [Example: 12 web server] :[C] Customer’s existing network:[If the customer does not currently hold any IP address space allocated from BTCL, please leave thissection blank.](i) Customer's Assignments to End users:[This information summarizes address assignments the customer has made to end sites from previous suballocations.]Actual Start Address Assigned [Example: 202.12.28.0] :Total Prefix Assigned to the end site [Example: /29]Netname of subnet in the APNIC Whois Database[Example: FOO-AP](ii) Sub-allocation infrastructure:[This information summarizes the actual address prefixes used for the infrastructure of the customernetwork receiving the sub-allocation.]Actual Start Address Assigned [Example: 202.12.28.0] :Total prefix assigned to the infrastructure [Example: /29]Description of subnet: [Example: server farm] :[D] Additional Information:This section is for providing other details which may help justify IP request. Forexample, (i) Network topology diagrams (ii) Detailed explanations of address spaceusage and subnetting plans. Separate page may be used for this purpose.:Signature of the Authorized person of the Customer______________ Date:___________Network Name :IP Address Allocated :Date of Allocation :For BTCL use onlySignature:________________________________ Date:_______________________