This RIPE Document is available in ASCII

% Provider Aggregatable (PA) Assignment Request Form


% RIPE NCC members can use this form to request a PA assignment. Please see 
% ripe-489 Link: /publications/docs/ripe-489/  for instructions on how to complete this form.


#[GENERAL INFORMATION]#
%
% Please add your RegID.

request-type: pa-ipv4
form-version: 1.2
x-ncc-regid: 


#[ADDRESS SPACE USER]#
%
% Who will use the requested address space?

legal-organisation-name:      
organisation-location: 
website-if-available: 

% Does this End User already have address space that can be
% used for this assignment? (Yes/No)

space-available: 




#[ADDRESSING PLAN]#
% As of 1 January 2010 assignments are for a period of up to 12 months.
% As of 1 July 2010 assignments are for a period of up to 9 months.
% As of 1 January 2011 assignments are for a period of up to 6 months.
% As of 1 July 2011 assignments are for a period of up to 3 months.
%
% How will the End User use this address space?
%
%       Subnet       Immediate    Intermediate  Entire   Purpose
%       size (/nn)   Requirement  Requirement   Period        

subnet:
subnet:
totals:

number-of-subnets: 

% Which netname will you use for this assignment?

netname:

% Will the End User return any address space?

address-space-returned: 


#[EQUIPMENT DESCRIPTION]#
%
% What equipment will be used and how will it use the requested
% address space?

equipment-name:
manufacturer-name:
model-number:
other-data:

equipment-name:
manufacturer-name:
model-number:
other-data:


#[NETWORK DESCRIPTION]#
%
% Please add more information if you think it will help us understand
% this request.


<add more information>


#[NETWORK DIAGRAM]#
%
% Have you attached a network diagram to this request? (Yes/No)

diagram-attached:


#[END of REQUEST]#