Customer Information Form


 
 *Note: To process your order, please complete the following form and click the SEND button below. A Solomon Galt Networks  representative will follow up with you shortly. Thank you and we look forward to working with you and your organization.

 
Primary Technical Contact Secondary Technical Contact

Name:
Phone:
Fax:
E-mail:

Name:
Phone:
Fax:
E-mail:

 
Billing Contact

Name:
Phone:
Fax:
E-mail:


 
Note: If any of the addresses below are the same, please indicate this with "Same address as [ship to/billing/etc.]".
 
Customer Address (US Mail) Ship To Address (US Mail)

Address:
City:
Attn:
Phone:

Address:
City:
Attn:
Phone:

 
Billing Address (US Mail)

Address:
City:
Attn:
Phone:

 

 Please select the services that you are interested in:

High-Speed Wireless Access

Document Repository

Electronic Filing

Pager/E-mail Service, Remote Control

Dial-up Access, Telecommuter Services

On-Site Support Services

Firewall, Monitoring and Remote Maintenance

Private Server Folders



 

Send Your Info. Here