Static IP Data Collection Sheet

Company Name: __________________________________________________

Reasons for static IP:

Camera system Router/Switches

Firewall Servers

Antivirus Device Dual WAN Balancer

Other, please state device(s) __________________________________

Amount of Static IP’s requested:

Package one: One Static IP Package three: Thirteen Static IP’s

Package two: Five Static IP’s

Customer information
Customer’s Name: _________________________

Customer’s Signature: _________________________

Contact No.: _________________________

Contact Email: _________________________

Date: _________________________