Verizon East Pre-OrderConnectivity Request Form
Customer Information
Date:05/25/2024
(*) Denotes required field
*Business Name
Contacts
*Primary
*First Name
*Last Name
*E-mail
*Phone Number
for Server/Lan
First Name
Last Name
E-mail
Phone Number
for Connectivity
First Name
Last Name
E-mail
Phone Number
for Maintenance
First Name
Last Name
E-mail
Phone Number
*Sender ID on
ISA Line
(ISA06 Segment)
GS Line
(GS02 Segment)
Receiver ID on
ISA Line
(ISA08 Segment)
GS Line
(GS03 Segment)
Other Information
Estimated Transaction Volume
 
*Environment
Please complete and submit two forms, one with your test information and one with your production information even if the information is the same.
CTE
Production
IP Address
Port
Target Directory Name
Server/Node
Name
*Customers OCN(s)
 
*Customers CCNA(s)
*Transport of choice
FTP Internet
FTP Dedicated
Interactive Agent
Dedicated
CORBA Internet
Please complete the appropriate section below for the transport of choice you select.
Complete this section if FTP has been checked
(*) Denotes required field if FTP has been checked
*Qualifier ID
*Password
*PGP File
*PGP Key Name
*Key ID
(Hex value)
*User ID
*Max Number of Concurrent Sessions (if less than 20 Specify)
Complete this section if Interactive Agent has been checked
(*) Denotes required field if Interactive Agent has been checked
*Qualifier ID
*Certificate File
Complete this section if Connect Direct has been checked
(*) Denotes required field if NDM has been checked
*User name
*Max Number of Concurrent Sessions in the License (if Not Unlimited)
Please complete this section if you are requesting a configuration change
Adding New Configuration
Changing Configuration
What is your current transport option?
FTP Internet
FTP Dedicated
Interactive Agent
Dedicated
CORBA Internet
Please indicate "New" transport choice
FTP Internet
FTP Dedicated
Interactive Agent
Dedicated
CORBA Internet
Complete this section if CORBA has been checked
(*) Denotes required field if CORBA has been checked
*Host name
 
*Verisign Certificate
 
*Reseller
CLEC
 
*AECN/ECC Code
 
*Vendor's ORB and Version
   
*Vendor's Security Service and Version
 
*CORBA Standard
   
*States
*Specified Transactions
 
Please complete this section if you are requesting a configuration change
Adding New Configuration
Changing Configuration
What is your current transport option?
FTP Internet
FTP Dedicated
Interactive Agent
Dedicated
Please indicate "New" transport choice
FTP Internet
FTP Dedicated
Interactive Agent
Dedicated
CORBA Internet

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