EmailMe Form - 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 *

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 Country / Region

Payment Preference

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