Please fill out this request form to the best of your ability. All equipment must be physically clean and decontaminated, with labels removed.
Be ready to provide a history of hazardous materials used, safety clearance, surveys, etc.
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| Contact Information |
| *First name: *Last name: |
| *Full e-mail address: |
| Alternate First name: Alternate Last name: |
| Alternate full e-mail address: |
| *Department: |
| If your department is not listed, please enter it here: |
| *Building: |
| *Room number: *Phone: |
*Speedtypes to charge(or UH account, or PO number):
Use the format: speedtype, percent to charge, speedtype, percent to charge, e.g. RES1234567,50%, RES456789,50% |
Equipment Information |
| *Equipment item: |
| *Manufacturer: | *Model: | *Serial number: |
*Describe the problem: |
Pressing the submit button will process your repair request and generate a confirmation number, and you should receive an email confirmation shortly. |
System designed by Mark F. Beno (6/2005)