Customer Information Form

First Name *

Last Name *

Company Name *

Company Address *

Suite, etc.

City *

State *

Zip *

Daytime Work Phone *

Company E-mail Address *

I acquire my equipment * Please select one all at the same time and on one lease or purchase agreement as needed with different lease expirations or replacement cycles as needed but with the same lease expiration date (co-terminus)

Copier Quantity *

How was equipment acquired? * Please select one Cash Purchase Cost per Copy (CPC) Facilities Management (equipment & labor) Lease Lease Buyout (after lease expiration) Rental

Term-if leased Please select one 1 Year 2 Year 3 Year 39 Month 4 Year 5 Year 51 Month 63 Month

Installation Date/Order Approval *

Gift Card Choice * Please select one Burger King Chili's Quiznos Starbucks Subway

* these fields are required