Internal Lead Form for Customer Care and Sales Associates

Required fields are marked with an asterisk (*).

Submitted by: *

Your Company: *

What kind of lead is it? *

Contact First Name* Contact Last Name*

Company Name*

Phone Number*

Ext:

Email*

Address* (of Equipment/Rental/Ship-to)

City*

State*

Zip*

What kind of equipment are they looking for?*

Notes*:

Do you know the part number(s) you wish to order? YesNo

Bill To:

Same as above

Company Name*

Contact Name*

Address*

P.O. #

City*

State*

Zip*

Order Information

Make

Model

Serial Number

Order Parts:

Please input as much information as you know and we'll help you find the part you're looking for.

Machine Information:

Make

Model

Serial Number

Concerns / Comments

What kind of equipment do they wish to rent?*

Desired Delivery Date*

Notes*

Please describe the problems experienced:

Please type your comments and/or questions below:

Lead Source (How did they find us?)*

Other source:

Please note: If you, somehow, managed to find this page and you’re not one of Bortek’s employees, you can simply ignore what’s here as it offers no value to you. We highly recommend checking out the content on these pages though!!

Bortek Industries, Inc.®