Section 1A. Uplink Services

Select Uplink Service type:

This is a brand new Uplink Site Survey Modify Existing Uplink Configuration De-Install and/or Re-Install Uplink Equipment Add studio equipment

How many channels do you want on the uplink?

1 2 3 4 5 6 No Change

Do you want a redundant channel?

Yes No

Provide uplink requirements in the space below:

Section 1B. Downlink Services

Select Downlink Service type:

This is a brand new Downlink Antenna De-Install and Re-Install Downlink Re-Install a Downlink Antenna Add a new Viewing Room to an existing site Add room equipment Retrofit Existing Equipment De-Install a Downlink Antenna Add a new IRD (Integrated Receiver/Decoder) to an existing site Add Peripheral Equipment Add Classroom equipment

How many IRDs will be installed with this installation?

1 2 3 4 No Change

How many viewing rooms will be installed with this installation?

1 2 3 4 No Change

What model IRD will be installed with this installation?

9235 9234

Provide downlink requirements in the space below:

Section 1C. IP Services, Space Segment, Or Other Work Requirements

IP Satellite Services Order/Inquiry:

Please define your requirements in the space below:

Space Segment Order/Inquiry:

Bandwidth Required MHz Bandwidth Required Unknown

Geographic Coverage Required

Space Segment Type :

C-Band Ku-Band

Class of Service: :

Non-Preemptible Preemptible

Link Type :

Simplex Full Duplex Asymmetric Duplex

Uplink Location : City, State or Province & Country

Uplink Antenna Size :

meters

Downlink Location : City, State or Province & Country

Downlink Antenna Size :

meters

Term :

0 - 6 months 1 Year More Than 1 Year

Date Space Segment Required : Month/Day/Year

Please define any additional space segment requirements in the space below:

Other Satellite Work Order/Inquiry.

Please define your requirements in the space below:

Section 2. Requestor Information

* Indicates required information

*Agency Name:

*Agency Point Of Contact (POC) Name:

*Agency POC Tel. Number:

*Agency POC Fax Number:

*Agency POC E-mail ID:

*Agency Alternate POC/Number:

*Agency Street Address (survey location):

*Agency City, State, Zip (survey location):

Section 3. Billing Information

Select Payment Method:

Purchase Order Credit Card

NOTE: You must complete either the Purchase Order Billing Information or Credit Card Payment Information section.

Purchase Order Billing Information

Purchase Order Number:

Contracts POC:

Contracts POC Tel. Number:

Contracts POC Fax Number:

Contracts E-mail ID:

Credit Card Payment Information (Information to be provided by POC)

Contact Name:

Contact Tel Number:

Contact Fax Number:

Contact E-mail ID: