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diff --git a/httemplate/edit/svc_circuit.html b/httemplate/edit/svc_circuit.html
new file mode 100644
index 000000000..3f9bad5b1
--- /dev/null
+++ b/httemplate/edit/svc_circuit.html
@@ -0,0 +1,54 @@
+<& elements/svc_Common.html,
+              'table'              => 'svc_circuit',
+              'fields'             => \@fields,
+&>
+<%init>
+
+die "access denied"
+  unless $FS::CurrentUser::CurrentUser->access_right('Provision customer service'); #something else more specific?
+
+my $conf = new FS::Conf;
+my $date_format = $conf->config('date_format') || '%m/%d/%Y';
+
+my @fields = (
+  { field         => 'providernum',
+    type          => 'select-table',
+    table         => 'circuit_provider',
+    name_col      => 'provider',
+    disable_empty => 1,
+  },
+  { field         => 'typenum',
+    type          => 'select-table',
+    table         => 'circuit_type',
+    name_col      => 'typename',
+    disable_empty => 1,
+  },
+  { field         => 'termnum',
+    type          => 'select-table',
+    table         => 'circuit_termination',
+    name_col      => 'termination',
+    disable_empty => 1,
+  },
+  { field         => 'circuit_id',
+    size          => 40,
+  },
+  { field         => 'desired_due_date',
+    type          => 'input-date-field',
+  },
+  { field         => 'due_date',
+    type          => 'input-date-field',
+  },
+  'vendor_order_id',
+  'vendor_qual_id',
+  'vendor_order_status',
+  'endpoint_ip_addr',
+  { field         => 'endpoint_mac_addr',
+    type          => 'input-mac_addr',
+  },
+);
+
+# needed: a new_callback to migrate vendor quals over to circuits
+
+#my ($svc_new_callback, $svc_edit_callback, $svc_error_callback);
+
+</%init>