Survey Form

First Name*

Last Name*

Your Title

Company Name

Email Address*

Phone Number

Fax Number

IT Contact Name

IT Contact Phone

Address

City

State

Zip Code

Message

Which server OS will the printer driver be installed?

Model

Do you have industry specific software?

What is the IP address for the imager/printer?

What is the subnet mask for the imager/printer?

What is the gateway for the imager/printer?

*Is there an open working network jack within 6ft?

If no, what is the distance to the jack?

Do you need wireless connections?

If yes, what type of connection?

How many stations will need to be set up to print by Allfax?

Do you wish to SCAN to EMAIL?Next 5 fields must be filled out in order to set up SCAN to EMAIL

What is the address of the SMTP server?

What is the email address to be given to the imager?

Outgoing mail server port #

Does your SMTP server require authentication?(if yes please have available upon install or add to notes below)

Does your mail server require SSL?

What is the DNS server IP address?If mail server requires authentication, put username and password in notes below.

How many email addresses will be set up by Allfax?

Email addresses to be set up.

Do you wish to scan to network folder?Requirements for scan to network folder are network path (ex. \\servername\sharefolder), user name, and password to access folder. Supply info in Network Folder Info Box or upload file with info.

Network Folder Info Box

Do you wish to use Inbound Fax Routing?

Field Label

If yes, what is the email address to be routed to?

Will we be installing FMAudit on a server or computer?Meter collection software (FMAudit) will need to be installed on a computer or server that is always on.

Server/Computer to install meter collection software

Sales Representative

NotesNetwork installations and reconfigurations are performed free of charge within the first 30 days of imager install. Any network configurations after the 30 days are subject to charge unless Connectivity Contract is purchased. If you would like to view what is covered, the Connectivity Contract Terms and Conditions can be viewed on the Service page.

Would you be interested in the Connectivity Contract?