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Stage 1: New Equipment Request

Contact First Name:

Contact Last Name:

Email Address:

Phone Number:

Site Name:

Department Name:

Address:

City:

State:

Zip Code:

Cost Center Manager
Name:

Email:

HIT Director
Name:

Email:

12-digit Cost Center (xxx-xxxx-xxxxx):

Is this a new device or a replacement?

Justification for request:

What functions do you require? (check all that apply):
PrintCopyFaxColorScan

Number of users for this machine:

Anticipated monthly prints/copies (if known):

If you have a need to scan, please state the reason: