DEX Imaging
Request for device relocate/removal - NSU
Unit type:
*
Printer
Copier
Select a Choice
*
Relocate
Removal
Effective Date
*
MM
/
DD
/
YYYY
Requestor Name:
*
First
Last
Email
*
Extension:
*
Approver Name
First
Last
Old Billing Code
*
New Billing Code
*
Relocation/Removal
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):
Special Instructions
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Comments
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