Lead Registration Form

Please complete and submit for each lead. This form registers the lead with ACOM, and ensures that the referrer is acknowledged as the source and owner of this lead. If lead is not registered with, or has not been in contact with ACOM within the last 6 months, ownership of the lead will belong to your company.

Items with an (*) must be completed for proper submission.

Referral Partner Information

Sales Person's Name:* Extension:*

E-mail:*

Lead Referral Information

Company:*

Contact Name:* Title:

Phone Number:* Fax Number:*

E-mail:

Address: Address (cont'd): City:

State/Province: Zip/Postal Code:

May we contact this client?

ACOM Solutions
2850 E. 29th Street · Long Beach, CA 90806-2313
Phone: (562) 424-7899 · Fax: (562) 424-8662
©2007 ACOM Solutions, Inc.