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Customer Order Form

Please provide the following information. It will be used to set up your account with us. You won't be charged anything for filling this out, we will contact you and help you pick the right services. We will charge after we have finished the service you ordered.

Personal Information:

First Name
Last Name
Date of Birth
Home Phone
Cell Phone
Work Phone
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
E-mail
FAX
Organization
 Website

How did you hear about us?

Web
Flyer
Word of Mouth
Referral
Other: 

Do you have High Speed Internet at your location?

Yes No

Preferred Technician:


Have you done business with us before?

Yes No

Special Comments or Requests:


PC Issue: (Be as descriptive as you can. Tell us the Brand, Model, and Operating System of your machine. When the issue happens and what programs you are running at the time. Let us know if you made any recent changes to your computer, if you have security software installed and if the subscription for it is active.)


Service(s) Requested:

Product Name

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