Company Name*                               Contact Name*
   
Address*                                         Business Phone*

City, St. Zip*                                   Email Address*
 
Number of Locations                    Number of employees
                                 1-10 10-20 20-50 50-100+

Number of computers:
  Please Select 1-5 5-10 10-20 20-30 30-50 50-100 100-200 200-500+

Hours of Operation:
  Please Select 8 to 4 9 to 5 10 to 6 12 Hours 24 Hours

Who is your current internet service provider?
  Please Select AT&T Comcast Other WOW Not Sure

What type of internet do you have?
  Please Select Unknowen Cable DSL T1 T3 ISDN Dial-up

How many times per month do you require technical assistance?
  Please Select None 1Time 2 Times 3 Times 5+ Times

Have you experienced any down time in the past year?
Yes    If yes, how long?     None 1 Day 2 Days 5 Days One Week
No

Do you have a current backup of all data?
Yes
No

Do you have any virus protection?
Yes
No

Do you have a network server?
Yes
No

Do you have key systems that your business relies on for day to day
operation?
Yes
No

Do you have any security sensitive data?
Yes
No

Do you have a budget for technology?
Yes
No

Please tell us about your business and any challenges your business struggles
with using technology.

Thank you for taking the time to fill in this form.  We will contact with you
as soon as we analyze the information and match your needs to one of our
service plans.