VIEWS: 3,007 PAGES: 1


             This form is for you to PRINT, FILL OUT, & SIGN. Give this form to your on-site technician.
   Before an NI43D On-Site Technician works on your computer it is advised that you backup all of your personal data
and files, as NI43D can not be held responsible for any loss of data. If you can not do this because your computer is
malfunctioning, our technician will attempt to backup your files for you, for an additional fee. If our technician is not able to
backup your personal data for whatever reasons applicable, your data will be considered lost. We will do every thing in
our power to save your files and personal data. If we can not save your computer s data, your only other alternative is to
send your hard drive or other storage devices to a lab.
   In order to fully refurbish your computer we ask that you provide us with all of your; original software, CD-ROMs,
DVDs, and CD-Keys. We require: a deposit of $75.00 and your signature on the form below in order to take your
computer and/or purchase new hardware and install it. This deposit will go towards the repair of your computer, if
applicable, otherwise it will be returned in full.
   Below is a diagnostic checklist. Check all the boxes that apply to your computer, our technician will fill out the rest.
Customer Name:                                                  Address:

Phone / Email:                                                  Zip Code:
    Computer won t turn on                      Computer turns off unexpectedly              Computer continues to freeze
    Computer runs slowly                        Bad / No Internet Connection                Computer display won t turn on
    Computer display distorted                  Computer has physical damage                Computer has other damage
    Drivers, Software, Firmware Issue           Viruses, Malware, Spyware                   System Files Corrupted/ Damaged
                                                                                            CMOS / BIOS
    Hardware is ajar / has failed               Hardware to be purchased                     Installed New Equipment
    Hardware is unrecognized                                                                 TESTED / CONFIGURED
    Internal Re-Wiring Required
    Internal Dusting Required
    Misconfigured Software                      400GB Storage Exceeded                      PERSONAL DATA CORRUPT
    Misconfigured Hardware                      Storage Device Not Taken (lab)              PERSONAL DATA INTACT
    No CD-Key / Account Information             No System Disks Available                   Expired Anti-Virus Subscription
    CD-Key / Account Information                System Disks Available                      Valid Anti-Virus Subscription
    Windows XP Home                             Windows Vista                               IMPORTANT SOFTWARE TO KEEP
    Windows XP Professional                     Windows 2000 / NT
    Windows 7 Beta                              Windows Media Center
    COMMENTS/ QUESTIONS                                                                 COMPUTER REPAIR ESTIMATE

If the computer in question needs to be taken in for further repair, we require that you print & sign your name below.
For more information please read our FAQ and Terms & Conditions at www.ni43d.com. Or call: 847.201.6154
(PRINT YOUR NAME HERE) Client Printed Name:
(SIGN YOUR NAME HERE) Client Signature:
Authorized NI43D Technician Signature:
________________________________ Date/Time: _________________

To top