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Name of your Company(Required)

Business Phone(Required)

What industry is your Company in?(Required)

Healthcare, Consulting, Financial Services, Construction, etc.

Brief description of your Company(Required)

Please tell us more about your company. What products and/or services do you offer?

Company Main Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Does your company have a different billing address?(Required)

Yes

No

Company Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about Galaxy IT?(Required)

Google Search

Facebook Advertisement

Referral

Radio Advertisement

Billboard Advertisement

Primary Point of Contact

Who should be the Primary Point of Contact for all IT communication?

Primary Account Contact Information(Required)

First Last

Email Address(Required)

What is your title within the company?(Required)

Direct Business Line(Required)

Business Phone Extension

If applicable.

Mobile Phone(Required)

Required for emergencies.

Secondary Account Contact Information

Who should we contact next if we are unable to get a hold of the Primary Contact?

Secondary Account Contact Information(Required)

First Last

Email Address(Required)

What is their title within the company?(Required)

Direct Business Line(Required)

Business Phone Extension

If applicable.

Mobile Phone(Required)

Required for emergencies.

Billing Contact Information

Billing Contact(Required)

First Last

Billing Email(Required)

Where should we send invoices?

Direct Business Line(Required)

Phone Extension

If applicable.

Payment Information

Secure Automatic Payment Authorization Form

Name on Card(Required)

Card Number(Required)

Expiration(Required)

MM/YYYY

CVC(Required)

Billing Zip Code(Required)

Does the credit card have a different billing address from the main company address you provided?(Required)

Yes

No

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Terms of Service

Terms of Service must be signed by an authorized manager within your company.

Who is filling out this form?(Required)

First Last

What is your title within the company?(Required)

Signature(Required)