Step 1: Contact Information:

How did you hear about us?

*Will this be used in court or binding arbitration? Yes   No  

If yes, please explain details

Media Information

1. Card Type: SD   Compact Flash   XD   Other 

If other, please explain Media Type:

Failure Information:
* 1. What type of failure occurred and when did it happen?  Were there any error messages? What (if any) recovery attempts were made?  What tools were used? *800 character limit

Image Information

* 1. What is the subject matter of the images that we are looking for? *800 character limit

Authorize the Evaluation

By signing below you authorize DIGITALMEDIX™, Inc. to proceed with the evaluation pursuant to the terms and conditions set forth in the Service Agreement.

Signature:______________________Date:______________

Please notate all drive positions and label each drive from 0 to end disk in the LUN.  Additionally, we ask that you provide us with the RAID controller card.  If this is integrated, please bring the whole server if at all possible.