MicroShop Systems - Customer Contact Form

95 W. Main Street - Suite 5-300
Chester, NJ 07930
908.891.2290
908.891.2291 (fax)

OVERVIEW

SERVICES

C U S T O M E R C O N T A C T F O R M

Please take a few moments to fill out and submit the online customer contact form below. The purpose of the form is to provide us with the necessary contact information for your company and the employees that we interact with. There are three specific contacts that we need:

         Technical 1 (primary contact)

         Technical 2 (secondary contact in the event Technical 1 is not available)

         The Billing contact

The Technical contacts are for us to use in the event that we need to discuss the system with someone. The Billing contact is for questions regarding invoices and payments.

If your company has remote offices or more than one site, please fill out multiple forms.

	COMPANY DATA
Company Name:
Address:
Address:
City:
State:	Zip Code:
Main Phone #:
Main Fax #:
Web Site:

	PRIMARY TECHNICAL CONTACT
Contact Name:
Address:
Address:
City:
State:	Zip Code:

Office # / Ext:
Fax #:
Cell #:
Home #:
Email Address:

	BACKUP TECHNICAL CONTACT
Contact Name:
Address:
Address:
City:
State:	Zip Code:

Office # / Ext:
Fax #:
Cell #:
Home #:
Email Address:

	BILLING CONTACT
Contact Name:
Address:
Address:
City:
State:	Zip Code:

Office # / Ext:
Fax #:
Email Address:

	Thank you !!!!!!!!