Contact Name:

Title:

Company Name:

Address:

City:

State:

Zip:

Email Address:

Contact Number:

Ext:

Contact Fax:

Cell phone/Other contact number:

Type of Business:

Please contact me by:

Email Phone

Best time to call:

Please select In 30 Minutes In 1 hour In 2 hours In 3 hours In 5 hours Next Business Morning Next Business Afternoon Night Next Week Next Month 2 Months 3 Months 4 Months Other:

Purchase Time Frame:

Please Select Immediately 1 to 2 Weeks 2 to 4 Weeks 4 to 8 Weeks More than 8 Weeks

Speed Requested:

Please Select Less than 20 PPM 20 to 35 PPM 35 to 45 PPM 45 to 55 PPM 55 to 75 PPM Over 75 PPM

Number of machines you are looking to purchase/lease:

1 2 3 4 More than 4

What is your budget per machine:

$1000 - $2000 $2000 - $3000 $3000 - $4000 $4000 - $5000 $5000 - $6000 Over $6000

If you are located in S. Florida or W. Pennsylvania would you like a leasing option:

Yes No

If you are located in S. Florida or W. Pennsylvania would you like a service contract:

Yes No

If yes what zip code will the copier be in:

Are you interested in:

New

Used

Refurbished

Will this copier be used in:

Business Home

Does the location have a loading dock:

Yes No

Will copier need to be moved upstairs: