MIRAGE Customer Registration Form.


Registration Form

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MIRAGE Z-128 Pro Registration Form.

Estimated time needed to fill this form is: Approximately 3 Minutes
All the fields marked as () must be completed:
  • Your First Name?
    		•
  • Last Name?
    		•
  • Your Position:
    		•
  • Company Name?
    		•
    Important:
  • Your E-mail Address?
    		•
  • Your Phone Number?
    		•
  • Your FAX Number?
    		•
  • Your Snail Mail Address:
    Check this box if this is a change of address notification

    		•

    Product's Type and Serial Number:
    NOTE: If you have purchased several units of the same type, you may choose one item and enter multiple serial numbers in the same serial number field separated by ","
  • Product's Model?
  • Product's Serial Number?

    • Monitor Information:
    In order to assist you with your future technical inquiries, we'll need to know the brand and the model number for your Monitor.,
  • Monitor Brand?
    		•

  • Others Brands:
  • Monitor's Model Number?
    		•
  • Video Cable Type:
    		•
  • Monitor's Tube Size:
    		•

    • Where did you prurchase your MIRAGE card from?
    1- MIRAGE Direct: Please answer the bellow questions:
    		 2- Other Sources: Please answer the bellow questions:
  • Your original invoice Number?
  • Date of Purchase?
    		•  Please indicate if purchased from a:
     Local Reseller Mail Order
  • Company Name?
  • Invoice#?
  • * Date of Purchase?
  • Company's Physical address & Phone Number or Web URL:
    		•

    How do you rate the following:
  • Pre-Sales Information:
    		•
  • Sales Services:
    		•
  • Product Installation:
    		•
  • Documentation:
    		•
  • Product's Performance:
    		•
  • Technical Support:
    		•
  • Comments, Questions or Instructions?
    (No technical support questions or driver inquiries please. If you need technical assistance with your MIRAGE product, please send e-mail to: tech@mirage-mmc.com).
     

    • © 1998 All Rights Reserved. MIRAGE Multimedia Systems, Inc.