Your Name *

First Name

Last Name

Delivery Location Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Onsite Contact *

First Name

Last Name

Onsite Contact Phone

(###)

###

####

How would you like to Scan? *

Scan to Email

Scan to Folder (SMB)

Scan to FTP

No Scan Setup Required

Receive Faxes? *

Print Faxes Immediately

Forward Faxes to an Email Account

Forward Faxes to a Shared Folder

I Do Not Use Fax

Please note, you must have an analog line for fax.

Yes, we have a "POTS" line, not VoIP.

No, we have VoIP and need to know our options.

Please acknowledge that you have read and accept the above terms and conditions. *

I have read and accept these terms and conditions.

Authorized Company Representative *

First Name

Last Name