Surfnet Quotation / VAR Dealer Information Request Form

To ensure a timely and accurate response to your request, please complete this form.

How did you find us?

TradeShows (Please Specify)

Word of Mouth

Search Engines (Please Specify)

Advertising

Did you see one of product(s)

References

Press Releases

Choose a kiosk - Please indicate the model and quantity required:

Stock Kiosks

Qty

Ready-to-Build Kiosks

Qty

Prototype Kiosks

Qty

Netflyer

Apollo(2 Stations)

Cello

Apollo(4 Stations)

Powernet

Avanti

I-Phone

Micronet II FX

Cellular

Lioness

ElantraNet

I-Quad (4 Stations)

Logger

Leaning Tower

Net Cruiser

Mailbox

Sea Shell

Millenium

Sea Side

Net Jet

Surf

Netflyer Sitdown

Virtuoso

Timberland

Wave

All systems complete with minimum 64MB RAM, 2.1GB HD, 1.44MB FD, 32XCD ROM, 2MB Video Card, 15" SVGA Color Monitor, Glidepoint Mouse, 56K Modem, Compact Keyboard, 233 MMX CPU

Custom Designed Kiosks

I have my own design

Processors

Pentium 233

Pentium 266

Pentium 300

Displays - Monitors

15" SVGA Colour

15" Touchscreen

17" SVGA Colour

17" Touchscreen

Other (specify)

Photo-Email Camera

Black & White

Color

Payment Acceptors

US Bill Mechanism

Canadian Bill Mechanism

Coin Mechanism (one denomination)

Credit Card / Smart Card Reader

Circuit Controller

International Coin / Custom Token Mechanism

Printers

3 1/4" Thermal Strip Printer

8.5"x11" Color Laser Printer

8.5"x11" Black & White Laser Printer

8.5" x 11" Telpar Thermal printers

Pointing Devices

Laser Beam Trackball

Touchpad mouse

10.

Questions, Comments, and Special Instructions

11.

Please tell us about yourself and your business

Please note that fields in BLUE COLOR are mandatory.

Your Name

Position

Department

Management	Purchasing	Sales	Production
Manufacturing	Quality Control		Operations
Marketing	Creative	Programming

Your Company Name

Your Company Address

City

State/Province

Zip Code

Country

Telephone

Facsimile

E-mail

Web Site

Please describe the nature of your business

How many people are employed by your company?

1 to 5	6 to 20	21 to 50	51 to 100	100+
Other(specify)

Do you have a deadline for the project that generated this quotation request?

	Yes	Specify
	No

What is your budget for this project?

Specify

Press and your request will be processed or to start again.