*Date:	(MM-DD-YY)        *Tech ID:
*Company/Name:
*Street Address:
*City:
*State/Province:	*Zipcode:
*Work Phone:	Cell:
Email:	Fax:

                Note:  *Denotes Required Information

          

*Computer:	Model Number:
Serial No.:
*Payment:	Cash Check (pay to: Hung Le) Other COD Net 30 - Upon Approved Credit                       *Amount:
*Problem Description & Comments:
Tested & Approved by:

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