Ande's Help Home Assistance Request Form

Welcome to Ande's Help 4 You. Please fill out the form as completely as possible and submit it. We will promptly provide an answer and / or quote to your request.

Contact Person:  

Position/Title:  

Company:  

Email Address:  

Telephone:Phone:     ext. 

Street Address:  

City:     St:     Zip:  

Your preferred day/time to schedule assistance:
Month:    Day:    Time:  ,am pm

Urgency:  No Hurry | Urgent | Emergency

Computer Information:

If you do not know the specific information, please type in Unknown.

Type of computer:   DesktopLaptop

Manufacturer:   | Model:  

Operating System:    Windows 98SE |   Windows Millenium |   Windows 2000 |   Windows XP
  Windows Vista |   Linux |   Other:  

How old is the computer?  (Please, round off to the nearest number.)  

Anti-Virus used:  (If unknown, or none, Please enter that here.)  

Description of problem, or Assitance Needed:
Enter problem here...

Your patronage is valuable to us. Your information will be kept confidential and will not be shared, sold or provided to a third party.

When you are finished filling out the form, you may print a copy for your records by clicking here.

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Warning!
For FireFox users.

In some versions of Mozilla FireFox, if you have to 'Refresh' this Request Form, the Security 'Captcha' Code box and other graphics will disappear. Some versions of FireFox do NOT support reloading of Graphics when doing a page 'Refresh'. You may need to clear your 'Cache' with the 'Clear Private Data' function under the 'Tools' menu, before you click on 'Refresh', to see the new Security 'Captcha' graphic.