AOLC | Drop Off Form

Name*

Surname*

Company*

Contact Number*

Email Address*

Address*

Red or Watery Eyes?*

Yes

No

Body Aches?*

Yes

No

Headaches?*

Yes

No

Blocked or Runny Nose?*

Yes

No

Fatigue or Weakness?*

Yes

No

Loss of Smell or Taste?*

Yes

No

Diarrhea?*

Yes

No

Nausea or Vomiting?*

Yes

No

Cough or Sore Throat?*

Yes

No

Skin Irritation?*

Yes

No

Shortness of Breath?*

Yes

No

Have you come in contact with a COVID Positive person?*

Yes

No

Temperature*

I herby confirm that the above questions were answered truthfully to the best of my knowledge and that I bind myself thereto.*

Item Control Number*

Dropped Off*

Laptop

Desktop

Mouse

Power Supply

Power Cable

CD’s (OS / Software )

Bag

Keyboard

USB Device

Other

Make*

Model*

Serial No*

Other

Usernames*

Passwords*

Description of Problem*

Technician Notes*

Customer agrees to the following terms: 1. The addition/removal of software or hardware can sometimes result in the loss or corruption of data. I will not hold AOLC liable for any lost data. 2. AOLC, the customer, understand and agree to these terms.*

Thank you!

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