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Name:
Phone:
Company:
Email:
Will this computer be replacing an existing computer?
Yes
No
The peripherals I want:
15" Monitor or Screen
17" Monitor or Screen
19"+ Monitor or Screen
Flat Panel (indicate size, above)
Laser Printer
Inkjet Printer
Scanner
Speakers
Webcam
Digital Camera
Other:
The options I want:
Sound/CD Audio
CD Burner
DVD Drive
Lots of extra memory
Lots of extra disk space
Modem (56k)
Quantity:
Budget:
(both of the above fields are optional)
I will be using this equipment for:
Gaming
Business
Graphics
Internet
My internet connection is: 
Dial Up
DSL
Cable
Broadband
Other
Will this computer be on a network?: 
Yes
No
Please provide any additional details below about your request. Include where and when you would like to have the Computer(s) delivered, and if any cabling will be necessary. If you are looking for a specific internal component or peripheral, please provide those details as well.
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