Lead Registration Form

This form is used by EPIC Connections to collect information needed to register sales leads. Please fill out the form as completely as possible.
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Lead Registration Date
MM slash DD slash YYYY
Master Agent Name*
Enter Master Agent name*
Partner Name (First and Last)*
Partner Company Name*
Partner Title
Partner Phone Number
Partner Email Address*
Partner Street Address
Partner City
Partner State
Partner Zip Code
Customer Contact First and Last Name*
Customer Company Name*
Customer Title
Customer Phone Number*
Customer Email Address*
Customer Street Address*
Customer City*
Customer State*
Customer Zip Code*
# of Contact Center Seats*
# of Employees
Current Contact Center Technology
Estimated Close Date
MM slash DD slash YYYY
Service Needed #1
Enter Services Needed
Service Needed #2
Service Needed #3
Description of Opportunity
File Upload
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Max. file size: 300 MB.
Please direct any questions regarding this form to Bill Pieper (bpieper@epicconnections.com) or 402-884-4700 x201.
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Email address
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Comments
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