PC DIAGNOSTIC & REPAIR FORM / ESTIMATE
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: _________________