PC Repair
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Date of Request: ____/____/_____
Requesting Party:
_________________________
General Description of Computer Problem:
_________________________
_________________________
_________________________
_________________________
_________________________
Computer Information:
Make: ___________________
Model: __________________
Operating System:
_________________________
Is the computer under warranty:
[__] Yes [__] No
Contact Information:
Name: __________________________
Address: _______________________
Phone: _________________________
Email: _________________________
Payment Method:
[__] Cash
[__] Credit Card
Amount Due: $__________________
________________________________
Customer Signature
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