Network Connectivity Site Survey for Copier-Printer

(812) 475-8895

Please download form, fill out and return to
Alternatively you can fill out and submit the web form.

Please answer all questions or check “No” as appropriate

Section 1: Account Information







IT Support:




Key Operator:





SBM Sales Rep.      Equipment Sold


Section 2: Physical Environment

Please examine the area where the copier/printer will be located to answer this section.

a.) Indicate the type of electrical outlet available for the copier/printer:
Note: The manufacturer recommends a dedicated circuit for the printer/copier.

plug 1115V, 15-amp Nema 5-15R        plug 2 115V, 20-amp Nema 5-20R        220V, 20-amp 220V, 20-amp Nema 6-20R

b.) Is there a nearby (active) wall jack for the network connection:    YesNo

c.) Is there a nearby (active) wall jack for the phone/fax connection: YesNo


Section 3: Network Type

Will the copier/printer use Wired (Cat-5) or Wireless connection: Wired (Cat-5)Wireless

If using Wireless, please provide the following:

Wireless Protocol:     802.11b802.11g802.11n

Wireless Encryption: NoneWEPWPA2Other

Wireless SSID: Encryption Key:


Section 4: Computer Workstations

Please specify the number of workstations that will print to the new copier/printer: (max 5)
(Please see limitations and liability form for information if needing additional machines setup)

Please specify the operating system(s) used by devices needing access to the copier/printer:


(Android and IOS support only for Air Printing) (Windows XP support limited)


Section 5: Software Applications

Please specify any specialty software or print stream application(s) that will print to the new copier/printer:

PostscriptIPDSAdobe Creative SuiteCitrix or Terminal ServicesCAD SoftwareSAPBarcode PrintingOther


Section 6: Network Printing

Will workstations print through a network server or direct to the IP address: ServerPeer-to-Peer

If printing through a server, please specify the server OS: WindowsMacintosLinux/SambaNovell NetWareOther


Section 7: TCP/IP Addressing

Will you use Static or DHCP addressing to deploy the copier/printer: Static (recommended)DHCP

Static addressing please provide:

IP Address: Gateway:

Subnet Mask: DNS Server:


Section 8: SMTP

Will the copier be used to scan documents by email: YesNo

SMTP Server Host Name or IP Address: Port#:

Authentication Type:



Security Protocol: SSLSTARTLSNoneOther

Port #:


Section 9: Network Destination

Will the copier be used to scan documents to a shared network location: YesNo

Individual workstationsNetwork Server

Shared Network FolderMapped Internal Storage

What operating system will host the network folder or mapped drive: WindowsMacintoshLinux/SambaNovell NetWareUNIX FTP


NOTE: Copier will require FQN of destination path. Please attach a list of FQN(s) if multiple paths are needed. Also requires account credentials to Read/Write to path.

Credentials: UN:  PW:


Section 10: Fax Requirements

Will the copier be used to send or receive faxes:                 YesNo

Is there an (active) analog phone port available for faxes: YesNo

Should incoming faxes:     PrintForward to EmailForward to Network Folder

If forwarding, please specify email address or network folder:


Section 11: Security Requirements

Are there security regulations that must be met: HIPAA (Medical)Graham-Leach-BlileySarbanes-OxleyHomeland Security

Are there any special security requirements that need configured during instillation? (I.E. – print/copy restrictions – departments – or authentication)

If yes, please provide contact information of person responsible for security requirements.





Section 12: Media Types

(Please fill out the information below, this will help us understand your needs with media types)

Paper weight (gsm) range:

Paper type (material – i.e. cardstock, gloss, etc…)

Paper Size Requirements: 8.5x118.5x1411x178.5x512x1813x19

Sticky back labels: YesNo

Envelopes:              YesNo

Estimated Monthly Volume: BW: FC:


Section 13: Cloud Connect/Meter Reads

     Machines will use Toshiba’s E-Cloud Connect encrypted and secure server to communicate Meter Counts and critical system backup information nightly and upon special conditions. The machine needs access to Internet gateway via Port443 HTTPS either directly or via Proxy. Alternative automated meter reading transmissions are possible however without E-Cloud data, delays in serviceability may occur as well as more acute data loss should an electronic failure occur. E-cloud allows the servicing department at Southern Business Machines a higher than average level of service on our equipment in our ongoing goal of increased customer satisfaction. In the event that neither E-Cloud nor alternative automated meter reading is possible due to customer network configurations or limitations, it is understood that manual meter readings are the responsibility of the customer to obtain or onsite reading charges may apply. Expanded white papers are available upon request.


Installation and/or Support Policy

1. Back Up Your Files.

When we provide our support, we may need to upload, move, delete, edit or overwrite certain files in your directories. We strongly urge you to make a backup copy of your files before requesting our technical support.

2. Support Coverage.

During initial install support will be provided only for matters pertaining to this survey and current scope of work. All other support matters will be handled on a “per instance basis” – Additional charges may apply.

3. Limitation of Liability

The customer assumes all risk associated with the installation and use of the software (including without limitation to all associated administration). In no event shall Southern Business Machines be liable whether in contract, warranty, tort (including negligence (whether active, passive or attributed), product liability or strict liability or other theory), for cover or for any indirect, incidental, special or consequential damages (including without limitation any loss of profits or data, business interruption, computer failure or other monetary loss) arising out of the use or inability to use the software or performance of any related services, irrespective of, even if Southern Business Machines has been advised of the possibility of such damages.

Furthermore, the Southern Business Machines support team advises that, all precautionary network software that you deploy in your environment (i.e. Firewalls, Spyware and Anti Virus software) be applied to any workstations and/or servers that are existing or provided, that will be running our software solutions. Also, when plausible, any hardware (computers) used for specific Southern Business Machines software solutions should be used solely for that purpose and not as an extra, common workstation.

While we at Southern Business Machines make every effort to check and test material at all stages of implementation, it is always wise for you to run an anti-virus program on all material downloaded from the Internet and/or shared files on your network.


Customer Acknowledgement

This document is to be completed by an authorized network administrator for the listed company.
The system data gathered in this document is confidential and will be used to properly configure Southern Business Machines solutions.

This information is required before our technicians can connect equipment to your network and is intended for simple network integrations, more advanced integrations such as LDAP, IPP, HTTP Printing will be handled personally. Contact Vincent Altmeyer (Service Manager) if more complex configurations are required as well as additional Information / Comments or Concerns.

Survey Completed By: Title:

Email Address:

Customer Signature: Date:


Additional Information / Comments or Concerns: