| First Name: (*) |
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| Last Name: (*) |
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| City: |
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| State: |
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| Phone Number: |
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| Alt. Phone Number: |
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| Email: (*) |
Please let us know your email address. |
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| How would you like us to contact you? |
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| Drive Make: |
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| Drive Model: |
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| Operating System: |
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| Drive Size: |
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| Is this a Server? |
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| Level of Urgency: |
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*Typical recovery turnaround time. Results may vary. |
| What is Failure Symptom? |
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| Briefly explain the Failure: |
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| Have any of your drives been opened or have any components been swapped? |
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| If "YES" please explain: |
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| Please type in the following four characters |
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