Free Media Collection Form

Media Type*

Disk Capacity

Data Loss Circumstances (Type the answer in front of each question):*

Contact Name*

Company Name

Phone Daytime

Phone Mobile*

Address*

City*

Post Code*

Email*

Collection Date Preference:*

DayMonthYear

PLEASE NOTE THAT YOU NEED TO MAKE SURE SOMEONE IS PRESENT IN YOUR PREMISES ON THE DAY THE FREE COLLECTION IS BOOKED SO THAT THE COURIER CAN COLLECT THE PACKAGE.

Check the box to indicate your agreement*

I Agree

Please verify that you are human*