Service Request Form

In order to assist support staff with troubleshooting and/or addressing this support request, please provide as much background information as possible and include detailed description of the issue being reported, corresponding screen captures, list of steps taken before issue occured, names of screens, etc.

Please note, fields marked by an * are required to submit this Service Request Form.

    Service Request Form

    Date Request Initiated:*

    Support Request Ref No.:*

    Customer Information

    Company Name:*




    Email Address:*




    Email Address:

    Problem Description

    Account Manager Information:

    Your Account Manager:*

    Your Account Manager Email Address:*

    Attach File:
    Please note the file size is restricted to 5MB.

    Authorization Information

    Authorization Option 1

    Authorization Option 1
    We authorize Netintegrity to research and develop functionality requested above on Time & Material basis without the need for a prior written estimate. We accept all charges related to this Service Request and will pay in full upon receipt of the invoice.

    Authorization Option 2

    Authorization Option 2
    We authorize Netintegrity to commence evaluation of this Service Request and provide an estimate prior to commencing any work. We accept all additional charges associated with preparation of this estimate. We acknowledge that the cost of the estimate will be calculated as follows: the greater amount between $150 or 30% of the estimated cost, which we will pay in full upon receipt of the invoice.Should we approve the estimate and authorize Netintegrity to proceed, Netintegrity accepts the following terms:

    • Approval to Proceed received by Netintegrity within 15 days from the day estimate was provided: A credit in the amount equal to the estimate amount charged will be applied to the final invoice for this customization.

    • Approval to Proceed is received after 15th day from the day estimate was provided: customer accepts all charges as invoiced for customization services rendered and agrees to pay such an invoice upon receipt.

    Customer selected to expedite this Customization Request and accepted 30% escalation fee surcharge to be added to the total cost of this service.

    We would like to expedite this Service Request and accept 30% escalation fee surcharge to be added to the total cost of this service.

    We acknowledge that all development, title and interest in, provided in relationship to this Service Request is exclusive property of Netintegrity Inc.