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Customer Name: ________________________________________________

Address: _______________________________________________________

City: ________________________ State: _________ Zip: ________________

Phone (H) : ______________________ Cell: ___________________________

Email Address: ___________________________________________________


Service Type:

[    ] Computer will not boot     [    ] Computer runs slow    [    ] Problem printing

[    ] Problem connecting to internet    [    ] Computer infected with Virus/Spyware

[    ] Set up wireless connection    [    ] Set up multi computer network

[    ] Set up virus and spyware protection    [    ] Install operating system

[    ] Email problems    [    ] Other: ____________________________________

Computer Information:

[    ] Desktop    [    ] Laptop

[    ] PC              [    ] MAC

Computer Brand: ____________________________________________________

Model # : _________________________ Serial # : __________________________

Year Purchased: ____________________ Memory Size: _____________________

Size of Hard drive: __________________ Processor Speed: ___________________

Operating System (XP, Vista, Etc. ) : ______________________________________

Do you have any idea what caused the problem?


What were you doing when the problem occurred?



Please try the following before submitting this form:

  • Check Power Plugs/ Connections:

Is everything plugged in, connected and seated firmly?

  • Check the Network Cable:

Is it plugged into both the computer and the wall outlet?

Are there blinking lights where the blue network cord plugs into the computer?

  • Log off and back on again.

  • Restart: Start > Shutdown > Restart > Then log back in.


What other things have you tried?



Billing and Payment:

  • The services will be billed in accordance with the fee schedule set out in Appendix A. Charges will be calculated in quarter-hour increments, with a minimum service time of one-half hour. All invoices are subject to applicable taxes.


  • PROVIDER will give you an estimate of costs before performing any services. However, estimates are not guaranteed. If actual costs will exceed the original estimate, you will be informed. You can then either authorize PROVIDER to continue the work or to stop when the estimate limit has been reached.



  • Payment in full is due upon completion of the work. Any parts, hardware or software ordered specially for your equipment must be paid for in advance.


  • Payment may be made by cash, credit card, Paypal, or debit.



  • Minimum charge for one technician is $150.00 for first hour and  $100.00 for additional hours. 


Credit Card Information:

Name (as it appears on credit card): _______________________________________________

Credit Card Type: _____________________ Credit Card # : _____________________________

CVC # (3 digit code on back of card): _____________ EXP (MM/YY): _____________________

Billing Address: _______________________________________________________________

City: _______________________________ State: _______________Zip: _________________


I authorize Computer Emergency Services to charge the card listed above for the service fee and recurring monthly fee (if applicable). These rates are subject to change.


Name: ______________________________________________________________________


Signature: _______________________________________ Date: _______________________

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