Address/Site Information
Business Name:
Physical Address:
Business Hours:
Main Phone:
Billing Address:
Billing Contact Name:
Billing Contact Email Address:
Billing Contact Phone:
LEAP Managed IT's onsite "Go-To" contact
Primary Contact Name:
Phone:
Email:
IT Contact Information
IT Contact Name/ Company:
Phone:
Email:
Physical Device Setup
Wireless or Wired Connection:
Stairs or Steps
Please Select
Yes
No
Power (15 or 20 AMP):
Please Select
15 AMP
20 AMP
Both
Wireless Information
WiFi Network Name:
WiFi Password:
Administrator Username and Password
Server Admin Username:
Server Admin Password:
Local Admin Username:
Local Admin Password:
Scan to Email Information
Email Provider (EX: Office 365, Exchange, Gmail):
SMTP Server:
Email Username:
Email Password:
Fax Information
Phone Number:
Registration Name (Send Out):
System Type
Please Select
LAN
VOIP
Scan User Information
Name
Email
Folder Name
End User 1
End User 2
End User 3
End User 4
End User 5
End User 6
End User 7
End User 8
End User 9
End User 10
Machine Information
Machine Info
Make
Model
ID
Physical Location
Machine 1
Machine 2
Machine 3
Machine 4
Machine 5
Follow up / Notes
Submit
Should be Empty: