SIPtech PBX — Enrollment Form

Customer Sign-Up

Siptech PBX Enrollment Form

Tell us about your business and current setup so we can build and provision your Cloud PBX. Fields marked * are required.

Primary Business Contact

First Name *

Last Name *

Date

Primary Contact Phone Number

Business (Billing) Address

Address Line 1

Address Line 2

City

State

Zip Code

E911 Address (if different from business address)

Address Line 1

Address Line 2

City

State

Zip Code

Business Details

Email *

Business Primary Phone Number

Company Website

Current Providers

Current Internet Service Provider

Current Voice Provider

Upload Current Bill or CSR (Customer Service Record)

PDF or image, 10 MB max. Contact Siptech PBX support for help.

Siptech PBX Service

Number of Extensions Requested

Number of Physical Handsets Required

Target Date for Number Porting (Full Production)

Caller ID

International Calling Required

Yes No

Agreements By checking this box, you acknowledge you have read and agree to our Terms of Service. *

E911 Disclaimer — E911 service is tied to your primary location. Any 911 calls made from any extension will result in emergency services being dispatched to the location on file. It is your responsibility to ensure that all users of the phone system understand the E911 location information.

E911 Acknowledgement — I understand the limitations of E911 service. *