Name *

First Name

Last Name

Phone

(###)

###

####

Are you able to visit GSS in Northern California for a system demo on a vehicle?

Yes

No

Do you require on on-site demo?

Yes

No

Date current system was purchased.

MM

DD

YYYY

What is the estimated purchase date of this system?

MM

DD

YYYY

What is the estimated budget availability date?

MM

DD

YYYY

Which of the following applies?

Direct Purchase

RFP/RFQ

Contact 1 responsible for purchase

First Name

Last Name

Contact 2 responsible for purchase

First Name

Last Name

Address for Demo

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ship to location where equipment will be received

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact at the ship to location

First Name

Last Name

Phone

(###)

###

####