Customer Information Form

What type of customer are you?* This field is required.Feel free to select both!

Business

Residential

What type of business do you run?* This field is required.Feel free to select more than one!

Advertising & Media

Arts, Culture & Entertainment

Automotive & Marine

Business & Professional Services

Construction Equipment & Contractors

Events & Event Providers

Family, Community & Civic Organizations

Finance & Insurance

Government & Education

Health Care

Home & Garden

Housing & Property Management

Legal

Lodging & Travel

Manufacturing, Production & Wholesale

Non-Profits

Personal Services & Care

Pets & Veterinary

Public Utilities & Environment Services

Real Estate, Moving & Storage

Recreation & Activities

Restaurants, Food & Beverages

Shopping & Retail

Transportation

Other

Business Name* This field is required.What is your business billing name?

Business Address* This field is required.What is the physical address?

Is your business mailing address the same as your physical address?* This field is required.Does USPS deliver to your physical address?

Yes

Business Mailing Address* This field is required.What is the billing address?

Business PhonePrimary business number used by the public.

If it's the same as your mobile or business number, leave blank.

Business WebsitePlease provide the website URL for your business

Business Email AddressPrimary business Email address used by the public like Info@BusinessName.com

If it's that same as your direct email address, leave blank.

Billing Email AddressBilling Email address that you would like CC'ed on all invoice Emails.

If it's that same as your direct email address, leave blank.

Customer Name* This field is required.Preferred First and Last name

Job Title* This field is required.Owner, General Manager, Assistant Manager, etc.

Office PhoneDirect business number to your office desk. If it's the same as your mobile number leave blank

Home PhoneHome landline phone number

Mobile Phone* This field is required.Personal or business cell phone number

Primary Email Address* This field is required.Your primary Email address

Local Address* This field is required.Physical local address in Mono or Inyo County

Is your personal mailing address the same as your physical address?* This field is required.Does USPS deliver to your physical address?

Yes

Personal Mailing Address* This field is required.What is the billing address?

Date of BirthUsed for discounts/specials

Additional Business Contact* This field is required.Do you have any partners/employees who are authorized to request 395Tech to do work on behalf of the business?

Yes

Additional Business Contact #1* This field is required.Preferred First and Last name

Job Title* This field is required.Owner, General Manager, Assistant Manager, etc.

Email Address* This field is required.Direct business Email address

Office PhoneDirect office phone number

Mobile Phone* This field is required.Personal or business cell phone number

Additional Business Contact #2* This field is required.Do you have any additional partners/employees who are authorized to request 395Tech to do work on behalf of the business?

Yes

Contact Name* This field is required.Preferred First and Last name

Job Title* This field is required.Owner, General Manager, Assistant Manager, etc.

Email Address* This field is required.Direct business Email address

Office PhoneDirect office phone number

Mobile Phone* This field is required.Personal or business cell phone number

Additional Business Contact #3* This field is required.Do you have any additional partners/employees who are authorized to request 395Tech to do work on behalf of the business?

Yes

Contact Name* This field is required.Preferred First and Last name

Job Title* This field is required.Owner, General Manager, Assistant Manager, etc.

Email Address* This field is required.Direct business Email address

Office PhoneDirect office phone number

Mobile Phone* This field is required.Personal or business cell phone number

Additional Personal Contact* This field is required.Do you have any family members who are authorized to request 395Tech to do work without your permission?

Yes

Additional Personal Contact #1* This field is required.Preferred First and Last name

Email Address* This field is required.Direct personal Email address

Mobile Phone* This field is required.Personal cell phone number

Additional Personal Contact #2* This field is required.Do you have another family member who is authorized to request 395Tech to do work without your permission?

Yes

Contact Name* This field is required.Preferred First and Last name

Email Address* This field is required.Direct personal Email address

Mobile Phone* This field is required.Personal cell phone number

Additional Personal Contact #3* This field is required.Do you have another family member who is authorized to request 395Tech to do work without your permission?

Yes

Contact Name* This field is required.Preferred First and Last name

Email Address* This field is required.Direct personal Email address

Mobile Phone* This field is required.Personal cell phone number

Addition Site InformationAll fields are completely optional

Front Door Code

Garage Code

Gate Code

Lock Box Code

ISP (Internet Service Provider)

Modem Ownership

ISP Account Number

ISP Security PIN

How did you hear about 395Tech?* This field is required.Feel free to select more than one!

AT&T Store

Bing

Business Card

Customer Referral

Direct Mailer

Facebook

Flyer

Frontier

Google

Instagram

KIBS/KBOV Radio

KMMT Radio

Mammoth Lakes Yellow Pages

Mammoth Times

MyMammothTech

Online Add

Optimum (Suddenlink)

Post Office

Print Ad

Sales Call

Sierra Wave

Sign

The Sheet

Twitter

Verizon Store

Yahoo

Yelp

Other

Customer NotesIf you would like to provide any more information please feel free to do it here.

Customer Information Form