IP Address Request Form

EMBARQ IP Services IP Space Request Form

Use this form to request additional IP Addresses.

Please complete all fields below; missing or inaccurate information will delay your request. This information will be used to submit Shared WhoIs Project (SWIP) documentation to The American Registry for Internet Numbers (ARIN). IP requests will be processed within 72 business hours of receipt. If you need assistance in completing the form please call our IP services support team at 1.800.603.8044 Options 1,1.

Contact Information
Company Name
Contact Name
Contact Phone #		--
Contact Hours
Contact Email
Your Circuit
Full Circuit ID
Network (WAN) Address
City, State (ex: Orlando, FL)

Most Recent IP Network Assignment
Please place your most recently assigned network assignment in the field below. The current utilization field should provide a clear, concise, and detailed explanation of how the address space is currently being utilized. If you have more than one IP network currently assigned please include the networks, utilization and the detailed description in the Additional Relevant Information field below.
Network Block		# of IPs available		# of IPs in use		Current Utilization
-- /21 /22 /23 /24 /25 /26 /27 /28 /29 /30
New or Additional IP Network Allocation Request
Please select the size of IP network that you are requesting using the Network Block drop down list below. Next, enter the number of IP addresses that you plan to utilize within the next three month period. The request justification should provide a clear, concise, and detailed explanation of how the requested IP address space will be utilized. Note: ARIN requires that at least 80% of the requested address space will be utilized within the next 3 months.
Network Block		# of IPs available		# used in 3 months		Request Justification
-- /21 /22 /23 /24 /25 /26 /27 /28 /29 /30

Additional Relevant Information

Comments / Questions

NOTE: EMBARQ follows ARIN's guidelines for IP address allocation as closely as possible. EMBARQ reserves the right to ask for additional information if deemed necessary.