• FIELDS IN  RED ARE REQUIRED. 

• BLUE FIELDS ARE REQUIRED IF YOU DO NOT HAVE A CUSTOMER NUMBER OR SUPPORT AGREEMENT WITH ICS. 

• IF YOU HAVE TERMS WITH ICS AND DO NOT KNOW YOUR CUSTOMER NUMBER SEND A REQUEST TO:  ACCOUNTING@ICS-AMERICA.COM

Please provide the following contact information:         

Customer #:
Name:
Title:
Organization:
Street Address:
Address (cont.):
City:
State:
Zip/Postal Code:
Work Phone:		Extension:
Mobile Phone:
Home Phone:
Fax:
E-mail:
Preferred Contact Method:	CONTACT VIA WORK # HOME # MOBILE # E-MAIL

Please describe the problem(s) you're having:

Problem Description:
Computer Name:
Domain User Name:
Domain Password:
Computer Make:
Computer Model:
Manufacture Date:
Serial # or ICS ID #:
Problem Severity:	SEVERITY MINOR MAJOR CRITICAL

What type of service are you requesting?

To Be Determined By ICS Technician Remote Support On-Site Support

BILLING INFORMATION:
Payment Method:	PAYMENT METHOD SUPPORT AGREEMENT NET TERMS CREDIT CARD CASH OR CHECK WARRANTY SERVICE
Credit Card Type:	CREDIT CARD TYPE VISA MASTERCARD AMERICAN EXPRESS
Name on Credit Card:
Credit Card Number:
Expiration Date:
3 or 4 Digit Security Code:
ICS CONSULTING RATES              ICS CREDIT APPLICATION

PLEASE READ BEFORE CLICKING SUBMIT:

By choosing "I AGREE" and clicking the submit button below you are agreeing to allow an Innovative Computer Systems Support Technician install ICS approved, remote administration software on your server or workstation for remote troubleshooting.   You also agree to a minimum service charge of 30 minutes at the remote support billing rate of $110 per hour if your issue does not fall under a support agreement, or Innovative Computer System warranty.  If your issue cannot be resolved by remote assistance, an on-site visit or depot repair may be necessary.  You also agree to the terms and conditions set forth in the following disclaimer:

INNOVATIVE COMPUTER SYSTEMS DISCLAIMER AND INFORMATION FORM

YOU MUST CHOOSE "I AGREE" TO CONTINUE

  I DO NOT AGREE I AGREE