| First name |
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| Last name |
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| Job Title |
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| Organization |
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| Street address |
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| Address (cont.) |
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| City |
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| State/Province |
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| Zip/Postal code |
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| Country |
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| Phone |
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| Fax |
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| Email |
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| Model# |
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| Quantity |
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Serial#
Note: If you have more than one serial number please, separate each serial number with semicolon (;) |
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| Date of Purchase |
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| Purchased From |
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| Where did you learn of TeleCLIENT Windows-Based Terminal? |
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| I'd like information on: |
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| Annual Sales in U.S. dollars |
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| Number of employees at this location |
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| What industries do you serve? |
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What hardware platform(s) will the TeleCLIENT be connected to?(mark all that apply) |
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| What operating system(s) is used on the hardware platform?(mark all that apply) |
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| What were the first three most important factors that influenced you to buy this TeleVideo product? |
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