Date: _______________________			Desired Completion Date: _________
Building________________________			Location: ________________________
		Move/Change		Add
Phone/Fax		______________		_______________
Computers, Printers, Copiers		______________		_______________
Network Connections		______________		_______________
Lights		______________		_______________
Electrical Outlets		______________		_______________
Plumbing		______________		_______________
Mechanical (AC, Heat, Etc.)		______________		_______________
Furnishings & Floor Coverings		______________		_______________
Locks, Alarms or Security		______________		_______________
Custodial Services		______________		_______________
Paint		Match Existing ___		New Color ________
Landscaping		______________		_______________
Moving Services		______________		_______________

Please return with drawing or detailed explanation of what needs to be done:
________________________________________________________________________
________________________________________________________________________

Project Estimate: $________ Budgeted dollars for project $ __________ A/C # __-______-_________-_____
Contact Name(s): _______________________________________ Ext. # ______________
Requester's Signature _________________________ Date: __________ Ext. #: _________
Budget Authority's Signature___________________ Date: ___________ Ext. #: _________

------------------------ DO NOT WRITE BELOW -- FACILITIES USE ONLY -------------------------

Project Number: _____________ Project Coordinator / Manager: _________________________
Comments: _____________________________________________________________
______________________________________________________________________
Contractor Name: _______________________________ Phone: _____________________

Copies: Original Requestor [ ] Facil Mgt [ ] Facil Eng [ ] UIS [ ] Campus Safety [ ] EH&S [ ]
Construction [ ] Property & Aux Services [ ] Landscaping [ ] Custodial [ ] Event Set-up [ ]

Attachments: Hazcom O.C. Reply [ ] Lockout/Tagout O.C. Reply & Program [ ]
Contr Reg. [ ] Hazard/Envir Assessment [ ]