| Date: | Model: | Sereal Number: | BIOS Password: |
| System Unit | Port Expander/I/O Adapter | Port Replicator |
| Floppy Drve | Battery-qty included | Additional Memory(___MB) |
| Power Adapter & Plug | CD-Rom Drive/DVD Drive | |
| PCMCIA Cards___________ | PCMCIA make and model:____________ | e.g., Modem, LAN |
| Hard Drive | Capacity:_________________MB |
| Please describe briefly the reason you are sending this unit in for repair:_________________________________________ _________________________________________________________________________________________________ |
| Before packing your computer: | |
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| (Unit may not be returned to you in its original box) | |
| In order to complite the repair of your computer,
it may be necessary to re-image the hard drive, which will destroy all data or files.
Computek and/or its agents are not responsible for the loss of data or files. Computek and/or its agents are not responsible for, and reserve the right to, remove any non- compatable hardware or coftware from your system. |
| Customer's Signature: | Date: |
| Name:___________________________________________________________ | |
| Address:________________________________ | Apt#:__________________________________ |
| City:___________________________________ | State:_______________ Zip:_______________ |
| Work Phone:____________________________ | Home Phone:____________________________ |
| Fax Phone:_____________________________ | Alternate Phone:_________________________ |