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.
Lead Registration Date
Date Format: 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
Date Format: MM slash DD slash YYYY
Service Needed #1
Enter Services Needed
Service Needed #2
Service Needed #3
Description of Opportunity
File Upload
Drop files here or
Please direct any questions regarding this form to Bill Pieper (bpieper@epicconnections.com) or 402-884-4700 x201.
- Send me a copy of my responses
Email address
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.