Customer Information Form

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Primary Contact

Business Name*

Name*

First Last

Office Phone*

Ext

Email*

Business Address*

STREET ADDRESS ADDRESS LINE 2 CITY STATE ZIP / Postal Code Country

Secondary Contact

Name*

First Last

Office Phone Number*

Ext

Email*

Secondary Address*

Same as Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing

Name

First Last

Office Phone

Ext

Address

Same as Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact and Additional Information

Emergency Contacts (up to 3)*

Name

Emergency Phone Number

Emergency Email

Tax Exempt*

Yes

*If yes, you will need to fill out a Tax Exemption Form. This form must be received before invoicing to be exempt.

Additional Information

Is there anything you want us to know or any information you want to clarify?

Locations

Do you have additional locations?*

Yes

How do you want to enter your locations?

Manually

Upload File of Locations (for over 4 locations)

Number of Additional Locations*

Second Location

Address

Street Address City State ZIP Code

Phone Number

Third Location

Address

Street Address City State ZIP Code

Phone Number

Fourth Location

Address

Street Address City State ZIP Code

Phone Number

Other Locations

Please enter the rest of your locations in the space below. Please start a new line for each location. Include name of business, address and phone number for each.

How many locations do you have?

Locations

Accepted file types: pdf, csv, png, jpg, jpeg, , Max. file size: 1 GB.

Would you allow us to have unattended access to your business?*

This is if we need to gain access to your business to make repairs while the business is closed.

Yes

To have unattended access to your location(s), you would need to provide us with copies of keys, access control badges, etc., required to access all IT related equipment that we manage. By selecting Yes, we will be contacting you to discuss further.

Signature*

Need Services?

CTi Main Site

Insert/edit link

Enter the destination URL

URL

Link Text

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Or link to existing content

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