Customer Information

Company Name

Address

City / State / Zip

Hours of Operation

Company Contact

Telephone number
ext.

Cellular phone

Email address

Installation Site Information (if different than Customer Information)

Site Location Contact

Site Location Address

City / State / Zip

Site Location Hours of Operation

Site Location Telephone number
ext.

Phone Contact Information

Phone System Vendor

Phone Number
ext.

Cellular phone

Telecom Carrier Vendor

Phone Number
ext.

Cellular phone

General Information

Do you have a Network Administrator?
Yes No

If yes, Network Administrator's Name

Phone Number
ext.

Cellular phone

Do you have access to the phone / wiring area?
yes no

If no, who is the contact person to gain access?

Phone Number
ext.

Cellular phone

Do you have access to the server room?
yes no

If no, who is the contact person to gain access?

Phone Number
ext.

Cellular phone

In the room where the server will be located, is the temperature kept at least 75 degrees F or less?
yes no

Is there a CSU installed? (for T1 installations only. A CSU is not required If using a channel bank card)
yes no

If yes, what is the make and model?

Server Section

Do you have designated locations planned for the new OPC server and component server? yes no

If yes, please describe

What will the OPC and component servers be placed on?

Is there space for the server, plus a monitor, keyboard and mouse?
yes no

(NOTE: If you intend to parallel your new and old system, ensure that adequate space and enough electrical outlets available for every server and workstation)

Will the OPC and Component servers share a monitor, keyboard and mouse?
yes no

If yes, will an A/B switch be provided by the client?
yes no

List the following for the component server:
Processor Speed

Memory

Operating System

Are dedicated electrical outlets available for the OPC server and component server?
yes no

What is the distance, in feet, between the electrical outlets and where the servers will be?

Is there a network connection available for the OPC server and component server?
yes no

If no, how will the system be configured?

For a Peer-to-Peer configuration, will a hub be available? yes no

If yes, what is the hub speed?

Does the network support TCP/IP protocols? yes no

List all protocols supported on the network:

Describe your backup process:

Are analog lines available for modem connection? yes no

If yes, how many lines are available?

If yes, what are the phone numbers for the analog modem lines?

If no, when will analog lines be installed for modem use?
(mo/dd/year)

Workstation Section

If you are using your own workstations, what is the configuration?

Telephony Environment

Will your phone system interface with the OPC server, or be separate from it?
interface separate

If interfacing, what type of phone system?

How many phone lines will be attached to the OPC server?

Do you plan to use T1 or Analog service with your dialer?
T1 Analog

Status of phone lines for our system?
not present installed running

If not present, when will phone service be installed for the dialer?
(mo/dd/year)

What type of redundancy do you have on your phone service?

Has the T1 provisioning been done?
yes no

If no, what date will the T1 specifications be met?
(mo/dd/year)

What is the port configuration?

Campaign Information

Do you have a written Agent script?
yes no

Database Integration

Are you providing a database?
yes no

If yes, what format is your data in?

Additional Information:

Please provide any additional information in the space below:

Authorizing Name

Site Survey completed by (if other than Customer)

Date this form submitted (mo/dd/year)

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