Fill in the items below then press the submit button at the bottom of
the form
or print form and fax to the number above
|
Contact
Information (*Items
Required)
|
|
*Name:
Invoice #:
|
|
*E-mail:
*Date:
|
|
|
|
*Address
1:
|
| Address
2:
|
|
*City:
*State/Province:
*Zip:
|
|
*Day
Phone:
Evening Phone:
Fax:
|
|
|
*Description of Service:
|
|
Long Description
or Special Instructions
Please be Specific: |
|
General
Questions (Optional)
|
|
Best time to
reach you:
Best
method to reach you:
|
|
How did you find us: Referral, Referral #, Mailer, Email, Other? |
|
|
Comments: |
|
|
How would you like
to pay: |
Check
Cash
Money
Order
Credit Card
CC Type:
Visa
MasterCard
Amex
Discover
Note: Our Standard Rate is $30.00 per hour for
Remote Support Service Customers. Additional Fees may apply.
|
|
Amount Due:
Paid Date:
Initial:
|
|
This form is on a secure server but will
be sent through email which is unsecured. Please DO NOT
include your credit card number on this form. It is only meant to get
basic information, online, from the customer to complete any work
related issues. It can also be used as an online receipt for work done.
ANY & ALL charges will be verified, by customer, before we complete any
payment transactions. |
100% SATISFACTION GUARANTEE
Thank you for your business. We stand behind our
products & services. If for any reason you are not satisfied with our
products or services you may apply, within 3 days of the transaction,
for a full refund. We reserve the right to attempt to correct any
situation before a refund is given.
|
|
|