Domain Name Worksheet Form - Dedicated Resource Center

Domain Name Worksheet

Completing this Domain Name Worksheet is a necessary step developed to insure that the DNS Management Administrator at Pacific Bell Internet Services obtains up-front information about your network. Please be as thorough as possible -- it is required to include the alpha/numeric name of your mail server and to include the alpha/numeric names of your web, ftp & proxy servers if applicable.
Requests to support for additional Domain Names require a separate form for each. Please refer to Domain Name Service for an explanation on charges. Upon receipt of the completed template the Provisioning Department will process your request.

1. DSL Line Number: ( ) -

Is this Enhanced or Business DSL?
Enhanced Business

2. Company Name:

DSL Turn Up date:

3. Customer Name:

Contact Telephone Number:
( ) -

4. E-mail:

5. Domain Name:

6. Have you registered your domain with the InterNic at http://www.networksolutions.com/? Yes No

a) If you are switching from another Internet Service Provider to Pacific Bell Internet, has a modification to Internic for transfer of technical authority been made?
Yes No

b) If you haven't and you registered with Network Solutions, do you want us to do the modification for you at an additional one-time charge of $100 per domain name?
Yes No

8. Do you want PBI to be your Primary and Secondary DNS at an additional one-time charge of $100 per domain name? Yes No

8. If you answered no to question 7, please provide your PRIMARY and SECONDARY hostname and netaddress information. Otherwise proceed to question 9.

Primary Server Hostname

Primary Server Netaddress

Secondary Server Hostname

Secondary Server Netaddress

9. Do you have a mail server software program? Yes No

a) If you do, then provide the Host name and the IP you want assigned:

b) If you don't, then you will need to purchase the software and then forward this completed form to us, or purchase Web Hosting. If you have any questions, call 1-800-833-2120.

10. If applicable, provide the IP address of your www server:

11. If applicable, provide the IP address of your ftp server:

12. If applicable, provide the IP address of your proxy server:

13. For Enhanced DSL Customers: Would you like to continue to use your pacbell.net and News access? Yes No

a) If yes, what IP Address would you like to assign to your pacbell.net and News access? This IP has to be different from your server IP(s).

14. Did you talk to a DNS coordinator? Please provide their name:

15. Please provide any additional comments or relevant information:

Send form by clicking "Submit" below, or
Send form back by E-mail to: prov-dns@pbi.net
Or Fax form to: (415) 896-5598
For DNS Needs, call: 1-800-833-2120
If PBI Sales/Web Hosting services, call: 1-888-PBI-SALE.

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1. DSL Line Number:	( ) -
Is this Enhanced or Business DSL?	Enhanced Business
2. Company Name:
DSL Turn Up date:
3. Customer Name:
Contact Telephone Number:	( ) -
4. E-mail:
5. Domain Name:
6. Have you registered your domain with the InterNic at http://www.networksolutions.com/?	Yes No
a) If you are switching from another Internet Service Provider to Pacific Bell Internet, has a modification to Internic for transfer of technical authority been made?	Yes No
b) If you haven't and you registered with Network Solutions, do you want us to do the modification for you at an additional one-time charge of $100 per domain name?	Yes No

8. Do you want PBI to be your Primary and Secondary DNS at an additional one-time charge of $100 per domain name?	Yes No
8. If you answered no to question 7, please provide your PRIMARY and SECONDARY hostname and netaddress information. Otherwise proceed to question 9.
Primary Server Hostname
Primary Server Netaddress
Secondary Server Hostname
Secondary Server Netaddress

9. Do you have a mail server software program?	Yes No
a) If you do, then provide the Host name and the IP you want assigned:
b) If you don't, then you will need to purchase the software and then forward this completed form to us, or purchase Web Hosting. If you have any questions, call 1-800-833-2120.
10. If applicable, provide the IP address of your www server:
11. If applicable, provide the IP address of your ftp server:
12. If applicable, provide the IP address of your proxy server:
13. For Enhanced DSL Customers: Would you like to continue to use your pacbell.net and News access?	Yes No
a) If yes, what IP Address would you like to assign to your pacbell.net and News access? This IP has to be different from your server IP(s).
14. Did you talk to a DNS coordinator? Please provide their name:
15. Please provide any additional comments or relevant information:
Send form by clicking "Submit" below, or Send form back by E-mail to: prov-dns@pbi.net Or Fax form to: (415) 896-5598 For DNS Needs, call: 1-800-833-2120 If PBI Sales/Web Hosting services, call: 1-888-PBI-SALE.