Contact Person:  Your Full Name    Purchase Order #
Business or Organization Name    Department  
Address   City   State   Zip 
Phone   Fax Number   Other 
Email Address   Website Address  optional
Contact person name where equipment is located   Phone
Address where equipment is located, If different from above
What are your business hours? 

Type of Equipment

     Computer Brand/Model   Serial #
                                                                                   State Tag #
         Printer Brand/Model    Serial #
                                                                                   State Tag #
         Copier Brand/Model    Serial #
                                                                                   State Tag #
Fax Machine Brand/Model    Serial #
                                                                                    State Tag #
       Scanner Brand/Model    Serial #
                                                                                    State Tag #

      Other (Type of Equip)
                    Brand/Model    Serial #
                                                                                    State Tag #

Is your equipment on a network? Choose One Yes No If yes, what type of network? 

Describe the problem you are having.


Referred By   Select One Our Technology Dept Our Purchasing Dept Google Search MSN Search Yahoo Search Lycos Search AtlaVista Search ICSGeorgia.Com RealNova.Com Lalrea.Com IBM Lenovo HP Toshiba Xerox Dell Lexmark Acer Canon Panasonic Fugitisu Gateway Sony U.S. Chamber Of Commerce U.S. Army Website U.S. Pentagon Website U.S. Dept Of Defense Website TV Billboard Radio Newspaper Direct Mail Business Acquaintance Friend Other




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