Member Signature

Company Seal

NIXA CONNECTION FORM

Completing this Connection Form enables NIXA to provide you the connection, perform the necessary admin, configuration and wiring work to allow you to connect.

1. Technical Contact Details:

1.1 For Normal Working Hours:

NamePositionMobileEmailHours of operation

1.2 Beyond the Normal Working Hours

NamePositionMobileEmailHours of Operation

2. Billing and Payment Contact Details:

Contact Person NamePositionMobileEmail

3. For the Purpose of listing at NIXA Website:

Company WebsiteEmail Address

Member Signature

Company Seal

Member Signature

Company Seal

4. ACCESS SERVICE DETAILS:

CIRCUIT CAPACITIES 100 Mbps 1 Gbps 10 Gbps Others (Please Specify):

Circuit ProviderExpected Date of Service Commissioning

5. ROUTER DETAILS:

5.1 Make and Model:

Height in UHeight in InchesDepth

6.2 IP ADDRESSING:

IP Address RangeFrom Where ObtainedProvider Dependent orProvider Independent (Portable)

6.3 BGP INFORMATION:

AS Number used for Peering at NIXAList of AS Number you expect to announce to peering members at NIXAList of IP Addresses you expect to announce to peering members at NIXA