Remote Computer Repair Request Form
First Name
Last Name
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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Nevada
New Hampshire
New Jersey
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New York
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Phone Number USA only
Email Address
Services
What version of windows are you runing?
Windows Vista
Windows XP
Windows 2000
Windows 98
Computer Services
$50 for the first fix, $.95 cents a minute thereafter
Flat rate - General tune up - $75
Flat rate - Full Pc Clean up -$125
Are over the age of 18 ?
Yes
No
Do you live in the usa?
Yes
No
Indicates Response Required
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