1.   First and Last Name                        Company Name

        

2.   New Clients:

      Address                                          City                    State     Zip

            

       Phone                    E-mail                          Payment Method

       Select Cash Check Paypal

       How did you find us?

      

3.   Please tell us about your computer

      Desktop        Laptop  

      Is the computer under warranty?   Yes      No    Don't know
 

      Make                Model                             Operating System  

          Select Windows XP Windows Vista Apple Other I do not know    

      Please list the users and passwords to login:

     

      Please explain the problem:

     
 

      Is this an emergency ?

      Yes         No  
 

      Special Requests

     

      Do you want us to backup your files?    Yes         No

      If so, please explain :

       

      Do you want us to re-install programs?    Yes         No

      If so, please explain :

     
 

     Do you want us to re-install accessories?    Yes         No

      If so, please explain: