| Request made by: | Extension: | Date of Request: |
| Department: | Account Number: | Budgetary Head: |
Install New Phone Extension(s) - Check all that apply |
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| Name of User________________________________ Location of Service_____________________________ | ||||
| Purpose: | __Voice | __Fax | __Modem | __Other ___________ |
| Phone equipment needed: | __Desk Set | __Wall Set | __Other ___________ | |
| Restriction Level | __Campus Only | __Pittsburgh | __Metropolitan | __International |
| Install Wiring: | __Voice Only | __Voice & Data | __Other ___________ | |
| Remarks:_________________________________________________________________________________ | ||||
| FOR OFFICE USE ONLY | Ext. issued __________________ | Compco entered ________________ |
| Div/Dept. Code ______________ | Received in Telecom _____________ | |
| Budget # ___________________ | Line activation charge _____________ | |
| Assigned to _________________ | Add, move, change _______________ | |
| MACSTAR entered ___________ | RJ ___________POS_____________ |