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3717 National Drive, Suite 210, Raleigh, NC 27612
Two Town Square Suite 315, Asheville, NC 28803
919.781.5790
828-684-7778
* Current Equipment Supplier:
(Select One)
Brother
Canon
Copystar
Duplo
Fujitsu
Gestetner
HP
KIP
Konica-Minolta
Kyocera
Lanier
Lexmark
MBM
Muratec
NEC
Océ
OKI
Panasonic
Ricoh
Riso
Samsung
Savin
Sharp
Standard
Toshiba
Xerox
Other
If other,
Approximate current lease term expiration
B&W Copy Volume
0
1-3,000
3,001-6,000
6,001-9,999
10,000+
B&W Print Volume
0
1-3,000
3,001-6,000
6,001-9,999
10,000+
Color Copy Volume
0
1-3,000
3,001-6,000
6,001-9,999
10,000+
Color Print Volume
0
1-3,000
3,001-6,000
6,001-9,999
10,000+
Where do you currently purchase your supplies (paper, toner, and staples)?
How often do you purchase supplies?
---
1x per month
several times per month
every 2 months
2x per year
1x per year
included in current contract
other
Do you know who your sales representative is?
--
Yes
No
Sales Representative's Name
Company Information
* Company Name:
* Your Name:
* Title:
* Telephone:
* Email:
* Company Address:
* City:
State/Region:
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AS
AZ
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CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
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LA
MA
ME
MD
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VI
VT
VA
WA
WI
WV
WY
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AB
BC
MB
NB
NL
NS
NU
ON
PE
QC
SK
YT
Zip/Postal Code:
Questions/ Comments:
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