SimpleAssurance Registration

General Information

*Indicates required information

First Name:*

Last Name:*

E-Mail Address:*

Company Name:*

Phone:*

Address1:*

Address 2:

Address 3:

City:*

State:

Zip Code:*

Country:*

Please select the relevant features of this program that you are most likely to use

Advanced Replacement

On-Site Spare Memory

Service Call Reimburse

Product Purchase Information (optional)

Date of Purchase:

Place of Purchase:

If other, please indicate:

1.	SimpleTech Part Number

Product UPC Code:

Quantity Purchased:

Server/Workstation Information (optional)

Please answer these questions pertaining to each manufacturer

Manufacturers of Servers/Workstations

DELL

IBM

(Other)

Number of Current Servers/Workstations

Number of Servers/Workstations Planning to Purchase

< 3 Months

3-6 Months

> 6 Months