Company Name:		Company Title/Position:
Location Name:		Contact Name*:		Contact Email*:
Address:		Contact Title:		Confirm Email*:
City:		Contact Phone*:		Contact Website:
State: -Select- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:		Contact Fax:

How many hotel locations need Internet Kiosks or Business Centers?

Please enter the number of rooms you have for each hotel:

Hotel #1		Hotel #3		Hotel #5
Hotel #2		Hotel #4

Have you ever had an Internet Kiosk or Business Center before?
Yes No

Do you have a Business Center now?
Yes No

Do you have internet Kiosks now?
Yes No

Do you have DSL, Cable or T1 service?
Yes No

Are you wishing to purchase or lease this system?
Purchase Lease

Are you looking for a no cost revenue share program?
Yes No

Please tell us more about your needs: