What is your first and last name? *

First Name

Last Name

What is the best telephone number to reach you at? *

(###)

###

####

Date trouble occurred *

MM

DD

YYYY

Time trouble occurred *

Hour

Minute

Second

AM PM

How many bars do you see on the WiFi icon (if known)

1 Bar

2 Bars

3 Bars

Maximum Bars

Does the device connect after several minutes? *

Yes

No