Department of Pediatrics :: Computer Order Form

Computer Order Form

Simply complete and submit the following form; a Department of Pediatrics Computer Services representative will contact you soon.

If you have questions, please call 919.681.6513.

Division name *
Employee name *
Email address *
Telephone *
Fax
Date of hire *
How is position funded? *
New position or replacement? *
If replacement, previous employee’s name
If replacement, is previous employee’s computer available? *	Yes No
If yes, enter CIS number
If yes, enter computer’s current location
If non-Melampus computer, enter computer ID:
Please provide justification if requesting a laptop:
Other comments:
Requestor name *
Requestor email address *
Requestor telephone *

* Required