Technology Site Survey

Fill out the form below or download a printable version and fax to 860.635.5280

Please tell us about yourself: (* denotes required fields)

Company Name *
Date *
IT Admin - Contact *
IT Admin Phone # *
Company Address *
City * State *
Company Phone *
Zip Code *

Equipment to be connected (i.e. Savin C4502) *
Network TCP/IP Address *
Network TCP/IP Subnet *
Network TCP/IP Gateway *
Network Primary DNS *
Network WINS *
Network Secondary DNS *
Network Domain Name *
Network Operating System *
Operating System Version*
Will the Device be connected to a Wireless Network? *
Does your Wireless Access Point recognize 802.11b? *

Multifunction Options Desired? (Select all that apply.)


Will you be scanning documents to Email? *
* If yes, Please provide the SMTP Information
SMTP Address
SMTP Authentication ID
SMTP Password
Will you be scanning documents to a computer network volume? *

The Installed Device will require Full Access Rights to the Scan Folder. If Scanning to a network share folder, a network User Login Account will be needed: Suggested Account and Password - Account ID: savin       Password: copier