|
Contact
Information
|
| Name * |
|
| Business
Name |
|
| Email * |
|
| Phone * |
|
| Best time to
contact you |
Morning
Mid
Afternoon Evening |
| Fax |
|
| Address |
|
| City |
|
| State |
|
| Zip
Code |
|
| Country |
|
| Computer
to be used for: |
Business
use Personal
use
Both |
Social
Security #: |
(Optional) |
| Yes
No |
Credit
check authorization. |
| How
would you rate your credit? |
Excellent
Good
Fair
Less
than perfect |
| Explanation
of credit / Comments |
|
| Interested
in referral program? |
YES,
I WOULD LIKE TO EARN A FREE COMPUTER! |
| How did
you hear about us? |
|
| What
keyword (s) did you use to find us? |
|
