Direct Access Card Order Form

Verizon Resale/CLEC Project

To Place an Order Please Complete this form and fax to Security Dynamics: 781-515-6580

Or Mail to "Security Dynamics/RSA 174 Middlesex Turnpike, Bedford, MA 01730"

Or use this URL http://www.rsa.com/products/
Do not email this form to Verizon.

Number of Cards required: ___________________________________________________________

(please place orders in bulk when requesting multiple cards to one company location)

Email Media to: Vicki Henderson (vicki.l.henderson@verizon.com)

Ship Cards to:

Company Name ______________________________________________________________

Address _______________________________Suite or Room #______________

City/State/Zip ______________________________________________________

Contact Name ___________________________Telephone # _______________

Billing Address (if different)

Company Name ______________________________ ATTN: Accounts Payable

Address ________________________________Suite or Room #_____________

City/State/Zip ______________________________________________________

Please Bill me and reference Purchase Order: ________________________________

(a copy of the PO must accompany this request)

Please Bill my Credit Card #: __ __ __ __/ __ __ __ __/__ __ __ __/ __ __ __ __

Expiration Date: __________________

VISA MASTERCARD AMERICAN EXPRESS

(Please Circle One)

NOTES: You should receive your cards from Security Dynamics/RSA (781-515-5000) within 5 business days. Please use WEB GUI User ID form on this site to inform Verizon of your Secure ID number and who belongs to, or contact your Verizon Account Manager to begin the process of SecurID card authentication. This process will take an additional 10 business days.

** Secure ID cards expire on the date listed on the back of each card.