HCHS ONLINE TECHNOLOGY SERVICES FORM Instructions: Please fill out all of the fields on the form below. It is important that you put the G number or Serial number of the equipment in question. We will contact you as soon as we have the opportunity.

PART I: CONTACT INFORMATION

Helix Faculty Member Name (your first and last name) Your E-mail Address jschmoe@helixcharter.net Helix Voicemail/Extension Date of request (please use xxxx/xx/xx form... ex, 2001/02/20)

PART II: DESCRIPTION OF SERVICE REQUEST

Type of Equipment (please click one that best applies) --Select one of the following choices that best matches-- PC Computer System MAC Computer System Citrix Terminal Station Media Technology equipment (television/VCR/laserdisc player/overhead projector/etc...) Other Inventory/G# and/or Serial# Description of Equipment (brand/model number/type of equipment) Location of Equipment (room # and location in room) Description of Services to be completed

PART III: ADDITIONAL COMMENTS

Please write any additional comments that you would like to include with this form.