Service Request Form

Service Request Form
Computer Chick Service Plan Request Form

Please fill out the following information and we will contact you to get your Service Plan set up. For faster service, feel free to call us during business hours and let us know you have submitted your form, or we can take all of your information over the phone. 304-253-4879
Customer Name *

First Name Last Name
Email *
example@example.com
Best Phone Number *
Please enter a valid phone number.
Billing Address associated with the Credit Card you will use for payment *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Which Recurring Service Are you Interested in? *
How many computers are you wanting to cover with this service plan? *
Anything else we should know?
Our Business Hours are:
9-5 Weekdays
9-3 Saturdays
CLOSED Thursdays and Sundays
(appointments may be available upon request for off-hours)
Should be Empty:

Computer Chick Service Plan Request Form