Portable Internet


	Try or Buy Request Form

Thank you for your interest in Portable Internet and our leading line of GPS Mobile Workforce Management services. Please complete the information below and you will be contacted by a Portable Internet representative within two business days. For immediate service call us at 1-877-4Vericom (483-7426).

(* indicates required fields)

Name*
Title*
Company*
Parent Company (if a subsidiary/franchise):
Enterprise ID (if a customer):
Address*
Address 2
City*		State* ZipCode*
Phone*		()- x
Cell phone:		()-
Fax		()-
Email*
Web-site:

Please complete the following questions to the best of your knowledge:

1. Please contact me regarding*:

Product Demonstration		Product Information
Place an Order/Trial		Pricing
Product Comparison: vs AVL vs other handheld products
Add Units		Add Features/Upgrade Edition
Payment Info		Support/Training/Installation
Becoming a Portable Internet Partner		Other (Specify)

2. I am interested in:

GPS Tracker GPS Forms Other:

Ultimate number of phones being/to be tracked or used.

3. My organization is a:

Company, Government or Educational Institution interested in using your products in our organization

Wireless Carrier Authorized Representative

Wireless network operator

Mobile handset manufacturer

Integrator/Software developer/VAR

Content provider

Other (explain):

4. If you are interested in using Portable Internet products in your business, which of the following best describes your company's industry?

Transportation		Distribution
Service/Repair		Construction
Government		Manufacturing
Utilities		Communications
Other

5. What other AVL or related products are you familiar with (product name/vendor)?

6. How did you hear about Portable Internet? Check as many as applicable. Please also list your Nextel Representative, DAE and contact information.

Search engine (please list which one)

Direct mail/email/fax from: Portable Internet Nextel Nextel Rep/Dlr

Portable Internet sales representative (Name: )

Carrier representative: (E-mail or Name: Cell Phone )

Carrier dealer/Authorized Representative/Motorola Dealer (which one)
(Email: Cellphone:)

Press Article (Publication: Date //)

Customer Referral (Co name/individual)

Advertisement (from where? )

Other (Please describe)

7. Comments or Questions: