First Name *

Last Name *

Email *

Phone *

State * INTL AL AK AZ AR CA CZ CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

Type * Education Customer Business Customer Healthcare Customer Reseller - Education Reseller - Business Reseller - Healthcare Reseller - Government Distributor Other

Title Group * Teacher Administrator IT Department Other Reseller

Name of District/School/Business

How would you use the charging solution? Devices charge overnight in school/org Devices charged at home and need an extra charge during the day Charging/storage needed for loaner/repair devices More than one use case Unsure

What grade levels need a charging solution? Unsure K-2 Elementary Middle or Junior High High School Higher Education Other

Preferred Mounting Option Unsure Wall Mount Stands A Mix Roller

Preferred Power Supply USB Power Standard Unsure

Make, Model, Size of Devices

Where did you hear about us? * Customer Referral Digital Ad Direct Mail Distributor Email Campaign N/A Online Search Print Ad Repeat Customer Reseller Social Trade Show

Anything else to share about your project and timeline?

I do not want to receive email communication from PowerGistics with exclusive updates on product information, new product launches, special offers, resources and invitations to events.

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