submission Form Test [/vc_column_text] "*" indicates required fields For Order No.First Name* Middle Name Last Name* * Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Address* Hardware Received Desktop Laptop Netbook Tablet Game Console All - in - One Server Keyboard Power Cord OS Disk Software Disk PC Component Mouse USB Device (Other) HiddenDesktopHiddenLaptopHiddenNetbookHiddenTabletHiddenGame ConsoleHiddenAll - in - OneHiddenServerHiddenKeyboardHiddenPower CordHiddenOS DiskHiddenSoftware DiskHiddenPC ComponentHiddenMouseHiddenUSB DeviceHidden(Other)Hardware DescriptionBrand Make Model Color Product Serial Username Password / PIN Username Password / PIN Username Password / PIN Current Device State*Initial AssessmentPower to PC Yes No Untested HiddenYes (Power to PC)HiddenNo (Power to PC)HiddenUntested (Power to PC)Video Displays Yes No Untested HiddenYes (Video Displays)HiddenNo (Video Displays)HiddenUntested (Video Displays)Boots to OS Yes No Untested HiddenYes (Boots to OS)HiddenNo (Boots to OS)HiddenUntested (Boots to OS)Error Messages Yes No Untested HiddenYes (Error Messages)HiddenNo (Error Messages)HiddenUntested (Error Messages)HiddenTechnician Notes*Client Notes*Terms and Conditions* I have read and agree to the Terms and Conditions *Service Level Agreement a) I understand the information provided above and I am aware of the potential loss of data or damage to hardware or software that may occur as a result of my device being repaired. b) I acknowledge and agree that Maine Geeks rely on information I have provided them in repairing my device. I acknowledge that Maine Geeks will accept no liability for any loss or damage to my device (including hardware or software) which arises out of incorrect or incomplete information provided by me. I acknowledge and agree that Maine Geeks will perform the device repair services with due care and skill, but further acknowledge that the liability of Maine Geeks for any loss or damage to my device (including hardware and software), however caused, is limited to supplying the service again. Name* Date* MM slash DD slash YYYY Add your signature* Digital Manually upload Signature submission Form Test – Maine Geeks 1 Day Mac & PC Repair in Bangor submission Form Test – Maine Geeks 1 Day Mac & PC Repair in Bangor Upload your signatureAccepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.HiddenSignature [/vc_column][/vc_row]