Customer # _____________________Name _____________________Phone number _____________________Email address _____________________

120VACLooking for a new system 24VACLooking to expand current system 12DCLooking to replace current system

YesIndoors only NoOutdoors onlyBoth indoors and outdoorsNot sure Coaxial

Fiber OpticsTwisted PairNot sure

InteriorParking LotPerimeter 5-10 daysHallways 10-30 daysBuilding 30-45 daysOther ( please specify) 45+ (please specify)

YesYes (please indicate qty) NoNo

Total number of cameras your system will require Yes1-3 No4-78-1516-31 Yes32+ (please specify) No

What lighting conditions will you need to record in?Daylight/continuously lit 9" - 14"Night 15'' - 19"Day and Night 20" - 26"Not sure 26'' - 32"

Wide AngleNormal $2,000 - 4,999Telephoto $5,000 - $9,999

$10,000 - $24,999$25,000+

Indoor Not sureOutdoor

ASAPWall Within the next monthCeiling Within the next two months

More than two months

Camera Mounting (specify qty of each)

Do you require IP cameras?

What is your estimated budget for this video surveillance system?

Will this system be used with Point of Sale?

Monitor Size

What is your buying timeframe for this system?

Will remote viewing be required?

Lens type (specify qty of each)

Will any of these be Pan/Tilt/Zoom (PTZ) cameras?

System Application

Camera Housings/Brackets (specify qty of each)

Please fax completed form to our sales department at 864-286-4942. Or call 1-800-964-8994 with any questions.

CCTV Site Survey Form

What are your DVR storage requirements?

Camera Power

Is Vandal proofing required?

What transmission method will you be using?

How would you describe your current video surveillance needs?

Location of Cameras - indicate number required at each location.