User Name:    Password:    Business Name:    Number of Locations:            1 2 3 4 5 6 7 8  Web Address:  Physical Address:  City:                         State:  Zip:  Phone:  Fax:  Email:  Owner Name:  SSN / Tax Identification No.:  Cell Number:  Owner/Service Email:  Service Manager Name:  Emergency Service No.:  Average Turn Around Time: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15    Preferred Dispatch Method: Phone: Fax: Email:  Number of Technicians You employ: Inside: Outside : Number of Service Vehicles:  Uniformed Filed Technicians? Yes No    Service Vehicles Identified with Company Info? Yes No  Method of Dispatching You Use For Your Techs: Computerized Visual 2-way radio Phone Pager Email  What days of the week are you available for On-site Service Calls? Mon Tue Wed Thu Fri Sat Sun  Type of Services You Provide: In Home (residents) In Busines Carry-In Depot / Mail in Repair  What is your Standard Mileage Radius for On-Site Service? 10 15 25 50 100  Rate for Additional Mileage? $ /Mile  Length of Your Repair Warranty: Parts : 30 60 90 180 365 Days Labour : 30 60 90 180 365 Days Hours of Operation 1 2 3 4 5 6 7 8 9 10 11 12   AM PM  To  1 2 3 4 5 6 7 8 9 10 11 12   AM PM Repair Rate By Size or Type Trip & Diagnose Charge Minor Repair Rate Major Repair Rate Flat Rate for Trip, Diagnose & Repair Carry In Repair Laser Printer Repair Color Laser Printer Repair Copier Repair Multifunction Repairr Fax Repair Thermal Printer Repair Line Printer Repair Plotter / Design Jet Repair Scanner Repair Copier De-Installation  What is your Parts Markup Rate (we usually allow 15% markup on all parts)? %

Note: All Parts must carry a minimum 90 days Warranty or the Manufacturers Warranty, which ever is longer.