Agent Name

Customer Name

Customer Phone Number

Lead Source—- Select One —-InboundOutboundChatYPExisting CustomerWord of mouthOther

Customer Email address

Lead Status —- Select Value —-Attempted to ContactContact in FutureContactedLost LeadNot ContactedQualified

Device — Select Value —DesktopLaptopPrimary PhoneTablet

Make and Model

Sale — Select one —YesNo

Amount

Plan

Comment