ICT SCAN®

*First Name:**
*Last Name:**
*Company or Organization Name:**
*Street Address 1:**
Street Address 2:
*City:**
*State/Province:**
*Zip/Postal code:**
*Country:**
*Phone:**
*E-mail:**	The ICT-SCAN ® Questionnaire and the "End User" software program will be sent by E-mail attachment to this E-mail address.


How did you hear about us?:

Use my contact address for my invoice address
Invoice address:

*Language:**	French planned end 2025, German and Spanish planned end 2026
*Company or Organization type:**	If Other, please specify here The ICT SCAN® can be performed for a company or organisation as a whole or for a part of it. The information given below will determine the scope and the price of the ICT SCAN®.
*Revenue last fiscal year:**	million The above revenue should be the total revenue or comparable figure of the company or companies within the scope of the ICT SCAN®
*Number of employees:**	The above number of employees should be the total number of employees of the company or companies within the scope of the ICT SCAN®
*Number of IT locations:**	The number of IT locations are the locations within the scope of the ICT SCAN®, where IT systems for the processing of (main) applications are installed and/or locations where IT personnel is present. Locations with only (front) office equipment and software should not be included in the above number.

If all above information is correct click on the "Next" button; you may continue with the order process or may make corrections.

ICT SCAN® price:	EURO excl. VAT
) I have read and accept the ICT SCAN® Terms and Conditions*
*On-Line Signature:**	First and last name with one space in between The on-line signature in this box must match the first and last name specified at the beginning of this order form

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