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Name:

City:         Zip Code:

Phone Number:

Email Address:

Services Requested: (Check all that apply)

<Please choose type of service> Repair Install Upgrade Setup

Computer    Hard Drive    Adapter    Memory    Network    Modem

Spyware/Adware Removal    Other

Operating System: --------------Please Select----------------- Windows 95 Windows 98 Windows ME Windows 2000 Windows XP Windows Vista Other Not known

Computer brand: (ex. Dell, IBM, etc.)

    Model name: Model Number:

Details of request:

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