Service Request Form
Date and Time of Service Call Desired
•
Date:
•
Time:
Select a time
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
Contact Information
•
Name:
•
Phone:
•
Address:
Mobile:
•
Company:
•
Email:
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Broadband:
Yes
No
•
If Yes:
Cable
DSL
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Please describe the problem
Referred by:
New Customer:
Yes
No
Additional System Information
Number of PC's or Laptops:
RAM
Operating System:
WiFi:
Yes
No
Brands and Models
•
Required Fields
PC Quest Inc. • Bluegrass Industrial Park • 10416 Bluegrass Parkway • Louisville, KY 40299 • (502) 495-1386
