BTG RMA Request Form

Request Quote Form:

Please complete the Request Quote form below, or click here to send a general e-mail.

How can we reach you? (Required fields are shown in red)

First Name: Last Name:

Company Name:

Physical Address:

City: State: Zip:

Phone (primary): Home Mobile Other

E-Mail Address:

Website:

How do you prefer we contact you?: Phone E-mail Mail

Best time to reach you?

Are you a current customer?:

What is your salesperson's name?

If No how did you hear about us?:

How can we help you?

Quote (Please provide as much information as you can below)

Printers

Type:

Receipt/Validation
Document/Passbook
Other

Manufacturer: Model:

Quantity:

Additional Comments :

Servers/Workstations

Manufacturer: Model:

Quantity:

Configuration requirements / additional comments:

Displays

Type:

LCD
CRT
Other

Manufacturer: Model:

Quantity:

Additional Comments :

Other peripherals and equipment

Type:

Pin pads / MSR / MICR
Sharp / Teller Machines
Cash Handiling

Check Scanners
Keyboards
Other

Manufacturer: Model:

Quantity:

Additional Comments :

Parts

Manufacturer: Model:

Quantity:

Part #

Additonal Comments :

General information

Type:

Asset Management
Branch Automation Software
Networking

Information Security
Service Programs

Additional Comments ::

Demonstration

Type:

Teller
New Accounts
Asset Management
WebEX Demonstration

Information Security
BSA Compliance Module
ID Authentication

Timeframe: Number of Participants:

Additional Comments :

Web site comments/suggestions

Please enter any comments or suggestions about our website:

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