Agent Name/EIN:

BBEU/BBIP reference:

End User telephone Number:

Has the local network and home wiring been eliminated as a cause of the issue (Y/N)? :

Has a new fault been raised to BTW (Y/N)? :

Which network is the customer on? :

What Products does the customer have?:

Please provide further information on the nature of the issue, the service being used and any further detail as appropriate.