Your Name *
Your Email Address *
Your State *
Dell Internet Reference Number *
Payment Method *
 Credit Card 
 EFT (Netbank) 
 Direct Deposit 
 Other 
Average Price per PC *
Number of PCs Ordered *
 1 - 2 
 3 - 4 
 5-9 
 10+ 
Has Dell contacted you? *
 Yes 
 No 
Have you cancelled your order already? *
 Yes 
 No 
Are you willing to be contacted by the media? *
 Yes 
 No 
Other Comments

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