T-CARE Service Request Form                     

1. Please provide the following TCARE Account information. List the TCARE POC.

   First Name
   Last Name
   Title
   Organization
   Work Phone
   FAX
   E-mail

    

2. Indicate the Incident Response Level Desired:

   Normal (5 Business Days) Urgent (48 Hours) Emergency (1-4 Hours) Scheduled Appointment Only (Call)

   
   

3. Enter Date & Time of Request (if not now):

   -- mm/dd/yy        -- hh:mm:ss am/pm

   
   

4. Enter Device ID Requiring Service (if any):

       Server Switch/Hub Router Printer Display/Monitor Cable Desktop PC Desktop MAC

   
   

5. Please contact this person about this request (if same as above leave blank):

   First Name
   Last Name
   Title
   Work Phone
   E-mail

    

6. Is this a Hardware Problem Only?

   Yes     No (Software)   Both (or Not Sure)

   
   

7. Please Describe the Problem as Clearly as Possible:

   
   

8. Select Any of the Following Special Conditions:

   Repeat Request  Specific to One User  System Wide Problem   

            (FLORA) - Fax to 708-349-1353 if the form does not work.