REQUEST FOR COPY/PRINT DEVICE
Please complete and submit this form.
Name
*
First Name
Last Name
Email
*
example@example.com
What do you need to purchase (printer, copier, fax, scanner, MFD)?
Is your request for a device replacing an existing machine?
Yes
No
If yes, what is the existing device (make/model#)?
If yes, is the device still in working order?
Yes
No
Purchase or Rental?
Purchase
Rental
What is/will be the number of users on the current/proposed device?
What is the monthly page count usage on your current machine?
If you are unsure of the page count how many reams of paper do you use per month? (ream = 500pgs)
Are you expecting this monthly page count to remain the same?
Yes
No
Will this connect to the network or to a desktop?
Network
Desktop
What functionality do you require on the new device?
B&W (only)
Color
Duplex capability (saves on paper usage)
Scanning
Faxing
Stapling
Hole‐punch
Paper (11x17capability)
USB
Wifi (Wireless)
Envelope printing
Other
When would you like this delivered?
-
Month
-
Day
Year
Date
Do you want the Printer monitored for toner levels, required maintenance and page counts? (Must be a networked printer)
Yes
No
Please provide the location for the new device:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing code/charge-back/PO#
Additional Notes/Comments:
Submit
Should be Empty: