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Customer Contact Information Company First Name Last Name Phone (Include Area Code) Email (Required) Request Service Agreement Quote Machine Brand and Model Built-In Features Duplex Finisher MailBox FAX SCAN DESK Current Total Page Count Estimated Monthly Copies/Prints Current Condition Working Non-Operational Note: OMS will schedule an inspection appointment for the equipment and provide an estimate for repairs or maintenance required. The equipment must be performing up to manufacturer standards before registration under service agreement. Desired monthly Coverage Plan Request All Rates Undecided 20,000 Pages Per Month 25,000 Pages Per Month 30,000 Pages Per Month 40,000 Pages Per Month 50,000 Pages Per Month 60,000 Pages Per Month 70,000 Pages Per Month 80,000 Pages Per Month 90,000 Pages Per Month 100,000 Pages Per Month 100,000+ Pages Per Month Additional Information

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