REQUESTER______________________________ PHONE #____ - ______________
DEPARTMENT ____________________________ LOCATION ___________________
ITEM TO BE REPAIRED : _________________________________________________
MODEL #, ID #, C OF C # : _______________________________________________
PROBLEM DESCRIPTION :
IS ITEM CURRENTLY IN USE ? YES _________________ NO _____________
DATE REPAIRS COMPLETED : __________ / ____________ / ____________
CHAIR'S SIGNATURE _______________________________________________