Help Request Form

Use this form to request help. Fill in all information as completely and accurately
as possible - so that we can focus on giving you the assistance you need. For on-site assistance, view our On-Site Coverage map. For our extremely reasonable rates, view our Service Rates.

This contacts my cell phone, e-mails my computer, and sends you a confirmation message.

If the is during our business hours, you will be contacted shortly. If sent outside of our hours, you will be contacted as soon as possible.

Thank You! = Bruce Koehler

Contact Information:
	First Name Daytime Phone	Last Name Nighttime Phone		Date E-Mail
	Business Home Home Office Small Office
	Your Address: ,
	Type of Request: Hardware / Software Help Networking / Wireless Web Design		Assistance / Mentoring Training
	What is needed? / What is wrong ?
System Information:
	Make: Model: Speed: mHz Memory: MB Hard Drive: GB
	Operating System: Windows Vista Home Basic Windows Vista Home Premium Windows 2000 Professional Windows 2000 Server Windows NT 4.0 Work Station Windows NT 4.0 Server Windows XP Home Edition Windows XP Professional Windows ME Windows 98 Windows 95
	Check all that apply:	Modem Network Card Wireless CD/RW		DVD/RW Scanner Digital Camera
	Printer? Yes No Model:

Enter the following Confirmation Code without spaces:

4 5 P Q 9 T 8 W Q

Help Request Form

Contact Information:

Your Address: , AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IN IL KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Type of Request:

What is needed? / What is wrong ?

System Information:

Make: {Select One} Acer AST Compaq Dell E-Machine Gateway Hewlett Packard Hi-Q IBM NEC Packard Bell Toshiba Other or Unknown Model: Speed: mHz Memory: MB Hard Drive: GB

Operating System:

Check all that apply:

Your Address:

,

Make: Model:
Speed: mHz
Memory: MB Hard Drive: GB