Company Name Name Street Address Address Line 2 City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Phone By providing your phone number, you agree to receive text messages from Visual Edge IT regarding sales, service and support. Message and data rates may apply. Email Location (Room Number / Department) How many devices need service? You may include up to 5 devices per form submission. Device Group 1 Device 1 ID Equipment ID Serial ID Serial Device 1 Serial # Equipment ID Device 1 Equipment ID What is the Issue for Device 1 What challenge are you having with the device? (error codes, jamming, image quality, etc)* Are you experiencing challenges printing to or scanning from a PC? Yes No Device Group 2 Device 2 ID Equipment ID Serial ID Serial Device 1 Serial # Equipment ID Device 2 Equipment ID What is the Issue for Device 2 Are you experiencing challenges printing to or scanning from a PC? Yes No Device Group 3 Device 3 ID Equipment ID Serial ID Serial Device 3 Serial # Equipment ID 3 Equipment ID 3 What is the Issue for Device 3 Are you experiencing challenges printing to or scanning from a PC? Yes No Device Group 4 Device 4 ID Equipment ID Serial ID Serial Device 4 Serial # Equipment Id 4 Equipment ID 4 What is the Issue for Device 4 Are you experiencing challenges printing to or scanning from a PC? Yes No Device Group 5 Device 5 ID Equipment ID Serial ID Equipment ID Device 5 Equipment ID Serial Device 5 Serial # What is the Issue for Device 5 Are you experiencing challenges printing to or scanning from a PC? Yes No Hrs. of Operation or Additional Comments Submit