Department Date

Individual Responsible for Equipment/Software

Phone Equipment/Software Location

Primary Use of Requested Equipment/Software:

(Check one) Administrative Instructional Research Service

Computing Equipment/Software Requested

Estimated Cost of Equipment/Software: $

Funding Source (Check all that apply): State Grant Service Income Contract

Data Communications/Networking:

Will the equipment be connected to the campus network? Yes No

Will the equipment be connected to a LAN? Yes No

Make sure departmental request is attached and contains all signatures. When approved, departmental request will be forwarded to Procurement for purchasing.

Institutional Approval Number ____________ Approval Date__________

Signatures:
________________________________________________________

(ACIT Representative)