CONTACT                                                            (NEW Customers, PLEASE fill out ALL information)

  Business Name:                  Check if NEW Customer

  Contact Name:      Contact Number:
  Secondary Contact Number:     Fax Number:
  E-mail:              Website:

 LOCATION

Street Address: Location: New Exisiting
                 City:    State:   Zip Code:

Same as Above
Billing Address:
                 City:    State:   Zip Code:

 INFORMATION

Current System Type:

Phone System Type:   Other Mitel SX200 Mitel 3300 Mitel 3100 NEC Aspire NEC Aspire S Toshiba DK 16 Toshiba CTX 28 Toshiba CTX 100 Toshiba CTX 670 Panasonic DBS Panasonic HD Samsung iDCS 500 Samsung DCS Compact           Other/Model:

Voice Mail Type:   Other Amanda Callware Solo Callware Callegra NEC Aspiremail NEC Aspiremail Plus NEC Intramail Mitel Express Messanger Panasonic Courier IFM Panasonic Courier PanaVoice Samsung SVMi Toshiba Strategy Toshiba iES32 Toshiba iVP8 Innovator       Other/Model:

Number of Lines:       T-1:                           Yes No Number of Phones:                    --  Digital:                  -- Analog:    Fax Machines:

(check all that apply) Internal Paging External Paging Auto Attendant Music on Hold Call Accounting

Notes/Additional Information:

(Please note anything that would help better serve you.)