APPOINTMENT REQUEST                                 (P)Fusion Intellect

Today's Date:                          Current Time:       Request Your Appointment Now!


SERVICE REQUEST FORM


E-Mail Address:
(Contact/Your) First Name:
(Contact/Your) Last Name:
Company Name:
Street Address:
Unit #:
City:
State:
Zip:
Country:
Daytime Phone:
Evening Phone:
Fax/Alternate Phone:
Date(s) Requested:
Appointment Time(s) Requested:
Best Time For Contact:

Emersion Technology Service Application

1) Will this be your first time receiving services from (P)Fusion Intellect ?
Yes No


2) Where is your desired service location?


2a) Is This Donation For E-waste Reuse & Reycle Pick-Up?
To sell your items click here. Note: All items you want to sell will not have a value. Donate them instead of adding to landfills.


2b) Please describe & list the items for reuse & recycle pick-up:(electronics only)


2c) What is the approximate (total) weight of the E-waste items for pick-up?


3) Address for service/ E-waste pick-up:


If you are donating E-waste (ONLY) click the request button below.


4)Which service('s) are you requesting?
(you may select more than one service by clicking on additional checkboxes.)

Computer Services:

Hardware/Software Installation
Computer Diagnostic
Computer Repair
Virus & Spyware Removal
Operating System Upgrade
RAM- Memory Upgrade
New Computer Build
New Laptop Build
Special PC Case Modifications
System Security Analysis

(Data Recovery rates are $50-75 each hour.)
Data/Password Recovery Microsoft O/S  1 Hour $75 1 Hour $112.50

Data/Password Recovery Apple O/S  1 Hour $75 1 Hour $112.50

Data/Password Recovery Linux/Unix O/S  1 Hour $50 1 Hour $75


Eliminate Satellite & Cable Bills & Still Watch TV! Choose An Emersion Technology Package Below.


Emersion Technology Installation Packages:
(9 to choose from)

Package 1 includes:     How Many Packages Desired?


Package 2 includes:     How Many Packages Desired?


Package 3 includes:     How Many Packages Desired?


Package 4 includes:     How Many Packages Desired?


Package 5 includes:     How Many Packages Desired?


Package 6 includes:     How Many Packages Desired?


Package 7 includes:     How Many Packages Desired?


Package 8 includes:     How Many Packages Desired?


A Customized System includes:     How Many Packages Desired?


In Home & Business Security Consultation:

Home & Network Security:     How Many Packages Desired?


Business & Information Security:     How Many Packages Desired?
(Your business information is crucial, protect it.)



5) How many rooms/offices will you need Emersion PC systems installed?


6) Are LCD TV's or Projectors Needed?
Yes No


7) Are surge protectors used in each room/office?
Yes No


8) Emersion Technology Hardware Installation (Only)?
Yes No


9) Emersion Technology Software Installation (Only)?
Yes No


10) Are you making reservations for In Home Consultation only?
Yes No


11) Are you making reservations for a Not For Profit Organization?
Yes No


12) If 'yes' to question 10, how many participants?


13) Any specific property access conditions or limitations we should be made aware of?
Yes No
If you answered 'yes' please provide a detailed explanation in the box below:


14) If paying with a gift certificate please enter the code here:
Enter the amount of certificate as issued:
Certificate Expiration Date:


15) How were you referred to (P)Fusion Intellect ?
If a registered (P)Fusion Intellect consultant referred you to this website, please type their referral number and name below:

Referral# Consultant:


16)
Credit Card Information
Card Type: Visa Mastercard Discover American Express

Name on Card:        

Credit Card Number: *last 4 numbers on card

Expiration Date: Month: Year:


17) Enter any promotional (coupon) codes here:


Have additional questions,comments, or special accommodations? Enter them below:



*NOTE: Your confirmation will be sent by e-mail along with all the details of your Emersion Technology PC System installation or E-waste pick-up.



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