EmailMeForm
Assistance Service Request
Service
*
Personal Use
Business Use
Both
If You Were Referred by Someone, Please Add Name Below
When Should We Begin Assistance?
*
MM
/
DD
/
YYYY
Assistance Seeking
*
Answering Calls/Messaging
Appointment Setting
Product Assistance
Other
If "Product Assistance" and/or "Other" Was Chosen, Please Describe
Assistance with Inbound & Outbound
Inbound Only
Outbound Only
Both
Days Needed
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time Slot(s) Needed
*
24 Hour
6am-2pm
2pm-10pm
10pm-6am
Will Date/Time Change?
*
Yes
No
Please Describe Change
If there will be a change in date(s) and/or times, please let us know here.
How Will You Want Your Retrieved Messages
*
Email
Call
SMS Text Message
IM Internet Message
How Often Will We Notify You of Messages
*
Daily
Hourly
Immediately
Bilingual Needed
*
Yes
No
$35 per day for bilingual assistance.
Contact Information
Name
*
First
Last
Business Name
Business Phone
###
-
###
-
####
Business Email
*
Personal Phone
*
###
-
###
-
####
Personal Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Payment Preference
Please select
Paypal
Credit Card
Money Order
Payment is due weekly. There is a $1.10 processing fee for payment made with Paypal and/or credit card.
Upon receipt of your information, we will contact you at your preferred contact method below. Once we have configured our services to fit your specific needs, an invoice will be emailed.
*Payment must be submitted prior to UCiC receiving your calls.
Follow Up Preferred Contact Method
*
Business Phone
Personal Phone
Business Email
Personal Email
What Other Information Would You Like Us to Know