SCL Domain and Cloud Services
Registration Form
Service Date and Level
Today"s Date
-
Month
-
Day
Year
Date
Desired Date of Service
-
Month
-
Day
Year
Date
Urgency
24 - 72 Hours
7 - 10 Days
2 - 4 Weeks
Other
Requestor
First name
Last name
E-mail Address
Phone Number
Business Information
Business Legal Name
Business Fictitious Name (DBA Name)
Business Physical Address
Business Phone Number
Business Domain ( Type "Requesting New" if none exists )
Assigned Consultant
DBP
SP
DL
JL
CL
SL
CW
WWD
Other
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Requested Services
Domain(s) For which service is being requested ( Enter desired name(s) and 1st, 2nd and 3rd Name Choices if no domain name currently exists )
Domain and Porting Services
New Domain Registration
Transfer Registration
Microsoft Office 365 - Domain Bind, DNS Setup
Google Apps for Work - Domain Bind, DNS Setup
Website Setup or Takeover
Voice Line Port
Fax Line Port
Cloud Services
Office 365 Enterprise - Setup and Monthly Maintenance
Google Apps for Work - Setup and Monthly Maintenance
E-mail Accounts
Shared Enterprise Cloud Storage with Granular Rights
Skype for Business
Web Hosting
Cloud PBX (VOIP) Phone Service
Paperless Fax
Number of Staff Enterprise Cloud and E-mail Accounts Desired
1
2
3
4
5
6
7
8
9
10
Other
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About Your Current Service Provider(s)
Please Note that you may share the requested Authentication Details using your desired mode of sharing authentication details or via this form, E-mail, or Fax
Your Current Domain Registrar
Current Registrar"s Website
Admin Authentication Details for Domain Registrar (You may reset your current password to non-personal value prior to sharing)
Your Current E-mail Hosting Provider
Current E-mail Hosting Provider"s Website
Admin Authentication Details for E-mail Hosting Provider (You may reset your current password to non-personal value prior to sharing)
Your Current Website Hosting Provider
Current Web Hosting Provider"s Website
Admin Authentication Details for Webhosting Account (You may reset your current password to non-personal value prior to sharing)
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Questions or Comments
Authorization to Process Request
I hereby attest that I am authorized to make decisions for the Business I delineated on this form and have provided accurate details to the best of my knowledge.
*
true
I understand that SCL Dynamics Inc. will prepare and forward an Estimate to me for Approval prior to proceeding with the services I have requested.
*
true
I understand that SCL Dynamics Inc. will treat my printed name on this form as my Legal Signature.
*
true
Printed Name/ Signature of Person Authorized to Sign
*
Date of Endorsement
*
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Month
-
Day
Year
Date
SCL DYNAMICS, INC.
18314 LEEDSTOWN WAY, OLNEY MARYLAND 20832
E-MAIL
SUPPORT@SCLDYNAMICS.ORG
PHONE
800.789.3905
FAX
301.799.3992
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