IT Managed Service Request
Phone: +1-888-217-7094 Email: Services@datacharlie.com
Full Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name/Your Name
*
E-mail:
*
Phone Number
*
-
Area Code
Phone Number
Business Type:
General Business
Government
State Government
Political Org
Medical Business
Non-Governmental
Individual Small Business
Healthcare
Other business type please state
Device Category For Support:
*
Computer
Email
Network
Phone
Switch
Router
Server
Printers
Others
What Operating System is being used
*
All custom applications being used
Please describe your Network and computer setup. (e.g.: non-network, peer-to-peer)
*
All Anti-Virus application(s)
Please provide the quantity of each device
*
Rows
Make
Model
Desktop
Laptops
Tablets (windows)
Mac
Servers
All-in-One
Router
Switches
Hubs
Printers
IP Camera
Please state you IT needs here
Services Period
*
Monthly
Six (6) Months
Annual (12 Months)
Two (2) Years
Three (3) Years
Select Appointment For Consultation
Authorized Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: