Request for device relocate/removal

Unit type: *

Printer Copier

Select a Choice *

Relocate Removal

Requestor Name: * First Last

Email *

Extension: *

Approver Name First Last

Old Billing Code *

New Billing Code *

NOTE: For removal no charges should be allocated to the current account for this ID# for use subsequent to the effective date indicated above

Now in possession of:

Make and Model:

US Imaging ID Number:

Serial #

Center/Department:

Current Location Address:

New Location Address (if applicable):

Network drop at new location?

Yes No

Current Account Charged:

New Account Charged (if applicable):

Please use the text box below to leave any special instructions or comments

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