/ ANX-ENX Connectivity Request Form /
Copyright 2010 by ANXeBusiness Corp. All rights reserved
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Section I: Introduction

The purpose of this document is to provide ANX with the necessary information to configure connectivity(in the form of an ENX VPN) between an ANX connected Trading Partner and an ENX connected User. All fields must be completed for ANX to accurately process the request. If you have any questions regarding the form please contact the ANXCustomerCareCenter at 877-488-8269. Please return the completed form, via email, to: .
NOTE: ANX will configure the ANX Trading Partner side of the VPN based on the information contained in this form. The ENX User should submit a similar request to their ENX CSP to have the ENX User side of the VPN configured.

Section II: Company Information

Company Name:
Address:
City: / State: / Zip:
Country: / ENX Registration Number:

Section III: Technical Contact Information

Name: / Email:
Phone: / Mobile:
Fax:

Section IV: Comments

Section V: Change Type

Add Delete Modify Requested Completion Date:

Section VI: Remote (ENX connected User) Information

Company Name:
ENX Registration Number:

Section VII: ENX VPN Information

LOCAL (ANXconnected Trading Partner) SIDE / REMOTE (ENXconnected User) SIDE
Gateway IP: / Gateway IP:
Protected Subnet/Host IPs: / Protected Subnet/Host IPs:
IPSec Platform/Version: / IPSec Platform/Version:

Section VIII: ANX Administration (for ANX internal use only)

1. Received Date
2. Information Verified Date
3. Completion Date
4. Completed By
5. IPSec Tunnel(s) Verified / No Yes
NOTES:

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