| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| Daytime Phone: |
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| Copier / Printer make and model to be installed:: * |
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Do you have a network drop near where the machine is being placed?: yes no
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Do you have cable to connect the machine?: yes no
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Network Servers: Vista / windows 2000 2003 NT/ Novell
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| Operating System: |
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Copier controller IP address assigned by Network Administrator: 192.168.1.11
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Gateway Address: 192.168.1.1
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Subnet Mask: 255.255.255.0
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Number of workstations to be connected: Basic install includes server and 1 client.
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Scan to Email: yes no
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Email: * |
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