Tech Impact Referral Form
Customer Referrals for GO2
Referee Contact Information
Referee Name
*
First Name
Last Name
Referee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referee Phone Extension
Please enter phone extension if applicable
Referee Email
*
example@example.com
Warm Introduction made between Customer and GO2?
*
Yes
No
Other
Customer Company Information
Customer Company Name
*
Customer Website
*
Primary Customer Contact Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Phone Extension
Please enter phone extension if applicable
Primary Contact Email
*
example@example.com
Is there a Secondary Contact?
*
Yes
No
Secondary Customer Contact Name
First Name
Last Name
Secondary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Phone Extension
Please enter phone extension if applicable
Secondary Contact Email
example@example.com
Customer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Service Address different than Primary Address?
*
Yes
No
Service Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Customer Desired Due Date
*
-
Month
-
Day
Year
Estimate timeframe if no specific date is determined
Requested Services
*
A/V Services
Access Control
Internet & Carrier Services
IT Hardware
Smart Hands Support
Video Surveillance
Voice & Data Cabling
Network Hardware (Switches & Other Computer Hardware)
Hosted VoIP PBX/Phone System
Other
Notes
*
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