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Technical Support Form
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Contact Information
Company
Title
Mr.
Mrs.
Ms.
Miss
First Name
Last Name
E-Mail
Phone
Ext.
Alt. Phone
Ext.
Fax
Address 1
Address 2
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
TeleCLIENT Information
Model
Terminal
Thin Client
Software Information
SW Version
Build Number
Additional Network Info (i.e. VPN, Wireless, etc.)
Total Number of Clients
Number of Problematic Clients
Questions or Comments
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