Service Request

Please fill out the computer services request form below with a description of the work to be performed. Filling out this form will allow me to help you much quicker. Thanks!

Name

Street Address(For In Home Service)

City (For In Home Service)

Home Phone

Cell Phone

Email Address

PC Type

PC Brand

Model Number

Windows Version

Problems You're Experiencing (Select All That Apply)

Will Not Turn On (No Lights)
Will Not Boot But Turns On
Freezing / Locking Up
Errors / Blue Screens
Operating Slower Than Normal
Multiple Popups / Browser Hijacks
Viruses That Cannot Be Removed
New Noises (Clicking / Grinding)
Strange Or Erratic Behavior

Length Of Time This Has Been An Issue

Detailed Problem Information (Anything Extra You Can Tell Me - Ex: Recent Software Installation, New Hardware Component, Running A Registry Editing Program)

When Would You Like To Drop It Off?

Priority Level

How Did You Hear About Us?

Referred By (This Person Will Recieve 10% Off Next Repair)

Other Comments

Visits today:	4
Visits yesterday:	5
Visits in this month:	99
Visits total:	6563
Max.daily visits:	791
Day of max visits:	18-10-2010
Max.monthly visits:	3522
Date since:	14-09-2010

	55%	MK (3586)
	27%	UNKNOWN (1754)
	2%	RU (141)
	2%	US (136)
	2%	UA (103)

Electrolux - Bitola