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Your Information

	Name:
	Company Name:
	Street Address:
	City:
	State:
	Zip / Postal Code:	/
	Daytime Phone Number:	ext. -
	Email:

What is the best way for us to contact you?

Phone E-mail Mail

The following information will help us determine which products are right for your communication needs.
If you do not wish to fill out the below section, please click here

Optional Information

Type of Business (choose one)	Coverage desired (choose all that apply)	Equipment needed (choose all that apply)
Contracting Education Industrial Health Care Government Farming Other:	Within Building Less Than a Mile 1-2 Miles City-Wide Coverage Other:	Portables Mobiles Base Stations Repeaters Rental CCTV Equipment Nextel Phones Other:

What Type of surrounding is your operation in? (choose all that apply)

Open Area
Light Forest
Heavy Forest

Large Hills
Lightly Populated Rural
Residential

Small City
Medium City
Large City

Have you ever used a Two-Way Radio before?

Yes No

If yes, What type?

How soon do you intend to implement two-way communications into your operations?

Within a week
Within a month
2-6 months
Within a year
Don't know yet

How would you like to handle any possible transactions?

Visa
MasterCard
American Express

Discover
Set up a Customer Account
Lease the Equipment

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