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  1.                        Customer Feedback Document
  2.  
  3. Please use this form to report any difficulties or offer any suggestions
  4. you may have regarding this product.  Thank you for taking your valuable
  5. time to assist us in this manner.
  6.  
  7. Product Name _____________________________________ Version _____________
  8.  
  9. Your Name ______________________________________________________________
  10.  
  11. Address   ______________________________________________________________
  12.  
  13.           ______________________________________________________________
  14.  
  15. City      _________________________________ State ______ Zip ___________
  16.  
  17. Phone     ______________________________________________________________
  18.  
  19. Computer  ________________________________________ DOS Level ___________
  20.  
  21. Nature of Feedback: Problem Report( )   Feature Suggestion( )   Other( )
  22.  
  23. Specific Problem/Request _______________________________________________
  24.  
  25. ________________________________________________________________________
  26.  
  27. ________________________________________________________________________
  28.  
  29. ________________________________________________________________________
  30.  
  31. ________________________________________________________________________
  32.  
  33. ________________________________________________________________________
  34.  
  35. ________________________________________________________________________
  36.       (Please describe exact activity when encountering problem)
  37.  
  38. Additional Comments  ___________________________________________________
  39.  
  40. ________________________________________________________________________
  41.  
  42. ________________________________________________________________________
  43.  
  44. ________________________________________________________________________
  45.  
  46. ________________________________________________________________________
  47.  
  48. ________________________________________________________________________
  49.  
  50. ________________________________________________________________________ 
  51.           (Use Back of form or additional sheets as needed)
  52.  
  53. Mail To:   Torbert Data Systems, Inc.
  54.            Post Office Box 9218
  55.            Chesapeake, VA  23321
  56.  
  57.