Full Name   

House Number        Street   

Town        Postcode   

Home Telephone        Mobile   

email address   

About Your PC:

If you are unsure of any of these details, just leave the fields as they are

Is there a Brand Name?    Unknown HP (Hewlett Packard) IBM Time / Tiny Dell eMachines Sony Simply Privately built from components Other (please specify if possible)    

Processor (CPU) speed in MHz    Unknown Up to 550 MHz 550 MHz to 1.6 GHz 1.6 GHz to 2.8 GHz 2.8 GHz and above Other     CPU Manufacturer    Unknown Pentium Pentium Pro Pentium 2 Pentium 3 Pentium 4 AMD K6 AMD Duron AMD Athlon AMD Sempron AMD 64 Other (please specify if possbile)

System Memory    Unknown Up to 64Mb 64Mb to 256Mb 256Mb to 1Gb 1Gb and above

Approx. age of your PC    Unknown Up to 1 year 1-2 years 2-4 years More than 4 years

Internet access    Unknown / None 56k dial up Broadband ADSL ISDN Other

Please provide a brief description of the problem:

Please accept my request for 12 months Repair & Breakdown Cover, costing £75.00.