The information requested helps us to better cater for our customers needs. All information is strictly confidential.
Personal Data
First Name Last Name Middle Initial Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone Home Phone Cell Phone FAX E-mail URL
Other Data
Processor Type
Product Name Intel AMD Other Other
Processor Speed
Product Name 100 - 300 300 - 500 500 - 700 700 - 100 Above
Hard Drive Size
Product Name 1GB - 4GB 4GB - 10GB 10GB - 20GB 20GB - 40GB Above
Ram Capacity:
Product Name 8MB 16MB 32MB 64MB 128MB Above
Do you have experience or skills in any area of Information Technology?
Yes No
If, Yes, please give details
Are you planning to purchase any computers, cell phones or personal planners in the near future?
If, Yes, Please give details
Please indicate by choosing appropriate membership:
Sales Representative Technical Sales Representative
Enter Representative Number ... in the space provided below.
Remarks
