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<br />r <br /> <br /> <br /> <br />.TOSHIBA <br />BUSINESS SOLunONS <br />FIorlda <br /> <br />37695 <br /> <br />SALES REP NO. <br /> <br />ORDER STAGE NO. <br /> <br />ACCOUNT <br /> <br />Cl NEW <br /> <br />NATURE OF BUSINESS <br /> <br />ACCOUNT NO. <br /> <br />ACCOUNT NO. <br /> <br />COUNTY <br /> <br />FAX <br /> <br />STATE <br /> <br />ZlP+4 <br /> <br />3 <br /> <br />4 <br /> <br />5 <br /> <br />6 <br /> <br />7 <br /> <br />a&.'-/ ()/f) <br /> <br />9 <br /> <br />10 <br /> <br />11 <br /> <br />DIGITAL INSTAll <br /> <br />SUPPORT PLUS Cl 1 <br />SUPPORT PLUS Cl 2 <br /> <br />PURCHASE With Credit Approval <br /> <br />Cl Cash Net Due On Delivery <br />Exp. Date <br /> <br />No. of Months <br /> <br />Monthly Payments <br />S <br /> <br />S <br /> <br />pluS tax. <br />First & last _ months rent <br />Security Deposit <br /> <br />s <br /> <br />Accessabilily <br /> <br />PAYOFF TO: <br /> <br />~ess <br />Contract # <br /> <br />ClStairs <br /> <br />Cl Ramp <br /> <br />Clloading Dock <br /> <br />Check Request Form Required Y I N <br />BUYOUT (Quote Required) <br /> <br /> <br />ACCEPTANCE: THIS AGREEMENT IS NOT VALID <br />UNLESS SIGNED BY AN OFFICER OF TOSHIBA <br />BUSINESS SOLUTIONS. <br /> <br />X <br />OFFICER APPROVAl <br /> <br />x 1)o.)#ip S~N, ~~V" <br />PRINTED CUSTOMER SIGNATURE <br /> <br />CORPORATE HEAOOlJARTERS <br />1011 S.W.3OTHAVENUE <br />DEERFIELD BEACH, FL 33332 <br />(954) 428-1300 <br />FAX (954) 429-9063 <br /> <br />SALES. SHOWROOM <br />1700 POWERlINE RD.. SUITE H <br />DEERFlaD BEACH. Fl33442 <br />(954) 428-1300 <br />FAX (954) 480-6713 <br /> <br />BRANCH OFFICE <br />175 N. flORIDA MANGO RD.. SUITE 301115 <br />WEST PALM BEACH. Fl33409 <br />(800) 526-7926 <br />FAX (800) 526-7906 <br /> <br />BRANCH OFFICE <br />14394 COMMERCE WAY <br />MIAMI lAKES. FL 33016 <br />(305) 826-9700 <br />FAX (305) 826-3350 <br /> <br />BRANCH OFFICE BRANCH OFFICE <br />3212 SOUTH U.S. 1 2815 DIRECTORS ROW. STE 700 <br />FORT PIERCE. Fl32982 ORLANDO. FLORIOA32809 <br />(561) 461-6224 (407) 852-1110. (800) 270-1869 <br />FAX (561) 460-6640 FAX (407) 816-1511 <br /> <br />FOR SERVICE AND SUPPLIES CAll 1-800-526-7926 . WWW cOPyco.com <br />