Southern Polytechnic State University
Pager Service Request
Agency: Southern Polytechnic State University
Work Order# (for Information Technology only)
Address: 1100 South Marietta Pkwy  Contact Phone#
Billing Acct.# 

(PLEASE DO NOT COMPLETE ANY FIELD THAT IS SHADED)
*** New Exchange Repair Close Out***
Model Serial# Decal# Cap# Pager# Name
       
       
       
       
FOR EXCHANGE ONLY ( If exchanging a pager, only complete the "Replacement Model Type" )
Replacement Model Type Serial# Decal#
Cap# Programmed By/Date

Pager Leasing Agreement
The item(s) described above are insured by GTA Telecommunications Division. The leasing agency is responsible for the $100 deductible for each pager loss. A written incident report must be filed with each claim. Mysterious disappearances or loss due to gross negligence, as determined by the Telecommunications Division, on the part of the agency employee is excluded. The leasing agency agrees to reimburse the Telecommunications Division for the full amount of the current fair market price for replacing the excluded lost item(s). The Telecommunications Division agrees to provide routine maintenance which is considered normal wear and tear at the above monthly rate.

Approved by:(signature)Date

This Section To Be Filled Out By GTA Personnel Only!

In Service Date:Billing Date:

Signed for AgencyDate
Signed for GTADate

Date Sent To RepairRemarks
Date Sent Back From Repair
Remarks