request for mis hardware, software and · pdf filestate of illinois department of human...
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State of Illinois Department of Human Services
IL444-4144 (R-02-17) Request for MIS Hardware, Software Printed by Authority of the State of Illinois -0- Copies
Request for MIS Hardware, Software and Services
Page 1 of 1
Requestor:
User I.D. #:
CPU Tag #:
Approval Name:
Title:
Signature:
Date:
*Required Estimated Total Cost: $
*CARS Approp Code:
*ORG Code:
State Fiscal Year (SFY):
*Subprogram Code: *Cost Center:
Project/Program:Location Code:
Telephone #:
City/Zip:
Address:
Cost Center Code (5-Character):Bureau/Facility:
Office:
Division:
Recipient:
Division:
Office:
Bureau/Facility:
Section/Unit:
Address:
City/Zip:
Telephone #:
User I.D.
User I.D.Contact:
Telephone #:
City/Zip:
Address:
Telecom Request: Data processing:Voice Line
Relocation
Pager
Installation
Relocation
MIS Use OnlyOther
Internet
Removal
Remote LAN AccessSoftware*
Hardware*
Cell Phone
Credit Card
Other
Data Line - MIS Use Only
Removal
LAN Jack
Fax Line
Phone Jack
Phone Set
Voice Mail
(9-Character) (2 Digit)
(4-Character) (4-Character) (5-Character)Item QTYNarrative Description of Request:
Justification:
Submit to: Bureau of Financial & Support Services 5020B Industrial Drive Springfield, IL 62703 217-557-3443 (Fax)