|
|
|
|
First Name |
|
|
Last Name |
|
|
Email Address |
|
|
Company |
|
|
Street
Address |
|
|
Address 2 |
|
|
City |
|
|
State |
|
|
Zip/Postal Code |
|
|
Phone Number
|
|
|
Alternate Number |
|
|
Fax Number |
|
|
Preferred Method of Contact |
Phone
Email
|
|
Best time to call |
Morning
Afternoon
Evening |
|
|
|
|
Service Call Type: |
On-Site
Service (at your home or business) |
|
|
Pick-Up
(at your home or business) for In-Shop
Service |
|
|
IT
Support Consultation (no charge) |
|
|
Personal
Technology Coaching or On-site tutoring |
|
|
Remote
Access Support (requires working
Internet connection) |
|
|
Scheduled
Telephone Support |
|
|
Web
Services Consultation (no charge) |
|
|
|
|
Appointment Date: |
(mm/dd/yy) |
|
|
|
Appointment Time: |
Please select a preferred timeslot:
No preference
8am - 10am
10am - 12pm
12pm - 2pm
2pm - 4pm
4pm - 6pm
Optional timeslot:
8am
- 10am
10am
- 12pm
12pm
- 2pm
2pm
- 4pm
|
|
|
|
|
Service
needed |
|
|
|
|
|
Will computer boot to Windows properly?
|
Yes
No |
|
|
|
|
Hardware needed |
|
|
|
|
|
Number of
computers requiring service? |
|
|
|
|
|
Have you used any of our services before? |
|
|
|
|
|
Computer type? |
Desktop
Laptop
Both |
|
|
|
|
What Operating system do you use? |
|
|
|
|
|
Internet Connection Type?
|
|
|
|
|
|
Who is your ISP? |
|
|
|
|
|
Anything else we need to know about you? |
|
|
|
|
|
How did you
find our Web site? |
|
|
|
|
|
If other,
please tell us how you found our Web site |
|
|
|
|
Check
this box if this is a correction to a
previously-submitted form
|
