Dispatch

How did you hear about Galaxy IT?(Required)

Google Search

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Referral

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Tell us who referred you so that we can thank them!(Required)

Business or Residential?(Required)

Business

Residential

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

Residential Address(Required)

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

Do you require our technicians to wear a face mask?(Required)

Yes

No

All of our wonderful technicians are fully vaccinated.

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 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)

Dispatch Form

We promise this will be quick!

Primary Point of Contact

Billing Contact Information

Payment Information

Terms of Service