Connectivity Solutions - Network Survey

Does the copier location have a 120v, 15amp power outlet located within 6 ft?
Please note, a power cable IS included with the copier/printer in a common 6ft length. Any power extensions must be provided by the customer and be in compliance with electrical guidelines.
- Yes
- No
Do you have an active network connection within 6ft of the printer/copier?
Please note, a network cable is NOT included with the copier/printer, the customer must provide the network cable between the copier and the walljack/plate. This needs to be a CAT5/5e/6 network cable with at least a 100Mbps connection to the network. Once the copier is plugged in, it should be able to receive link from the switch or network device and be able to acquire an IP address from a DHCP source and/or be statically assigned to work on the network.
- Yes
- No
Please describe the physical environment where the copier/printer will be delivered.
Do you have any stairs, elevators or other obstacles that could prevent delivery of your device?
Company/Parent Company Name:
Company Zip Code:
If you are a 3rd party IT company filling this form out for your client, please specify the client's company/parent company name:
IT/Network Contact:
Full Name Email Phone
What Operating Systems Are In Use?
- Windows 8
- Windows 10
- Server 2012, 2016 or 2019
- MacOS 10.X and up
Do you have an existing Windows Print Server?
- Yes
- No
If yes, please provide server name or IP Address:
If no, how many users need to be set up to print locally?
LAN/Network Information For Copier/MFP:
Copier/Model: Department/Room#: IPv4 Address: Subnet Mask: Gateway: DNS: Domain Name:

Please specify the network information you would like your copier/mfp device to be pre-programmed with. To add more fields click the (+) sign at the end of the current row.
Email Setup
SMTP Server: SMTP Port: FROM Address:
SMTP Authentication:
- Yes
- No
*
Username: Password:
SSL / TLS:
- Yes
- No
**Scan to folder:
- Yes
- No
**Scan to folder requires a user account to have read, write, and modify permissions.
Department IDs or User Codes:
- Yes
- No
FMAudit Contact
Your service agreement includes secure FMAudit software that is used to collect your meter readings automatically. Please provide the email address for the person who would install this on a server or computer:
Subnets For Discovery
FMAudit needs to discover your printers and copiers in your network, please provide a list of your subnets/networks in your environment so we can properly discover your printers/copiers.
Example: 192.168.100.0/24 or 192.168.100.0 255.255.255.0
Would you like to be setup for Automated Toner Replenishment?
Once FMAudit is installed, would you like us to review your account to see if it is a match for our free automated toner service?
- Yes
- No

Network Survey

Rather than have IT input information into your new device at the time of delivery, we can enter all of that information for you. This way when your new equipment is delivered, it can be used immediately.

Pre-Delivery Network Survey

Copier/Model:	Department/Room#:	IPv4 Address:	Subnet Mask:	Gateway:	DNS:	Domain Name: