Helpnerds: Onsite PC Repair,Computer Repair Fast !

Onsite Service Call Request Form

Is this for your home or business?

First name:

Last name:

Company Name:

(If Applicable)

Address:

City:

State/Prov:

ZIP:

[We may be able to contact you quicker if we have more than one phone number]

Home Phone:

Work Phone:

Ext

Cell Phone:

Choose your main phone line:

Email:

Confirm Email:

How many machines are at this site?

Operating system(s) in use : [Select ALL the operating systems that apply:]

What type of Internet Connection do you have?

Describe your service needs:
[Please include details such as your Operating System version, brand name and or model of machine(s) and any other relevant information.]