Name: First: Last: Street Address: Suite/Apt: City: State: MA CT RI Zip: Phone: Secondary Phone: New Customer? No Yes Type of computer: Desktop Laptop Other Brand: Acer Asus Compaq Dell Gateway HP Other Operating System: Windows 7 Windows Vista Windows XP Windows 2000 Windows 95 Windows 98 Windows ME Mac OS 9.X Mac OS 10.X Linux Other / Unknown How long have you owned your computer? Less than 1 year 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years More than 7 years Description Of Problem: Please be as descriptive as possible, it will help us to serve you better. Preferred date of service call: MM 010203040506070809101112 / DD 010203040506070809101112131415161718192021222324252627282930 / 2010 Preferred time: 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 AM PM Email: * Please note: This is a request form. All customers will be contacted for verification and scheduling. If you need assistance immediately please call our location directly.
