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<body>
<table border="0" cellspacing="0" cellpadding="6" width="99%" id="document-display">
<tr>
<td>
<p>
<span class="sub"></span>
</p>
<p>
<p>
<p class='docheader'><strong>Online PC Equipment Request Form</strong></p>
<script language='Javascript' src='/common/js/formfunc.js'></script>
<form action='/www/form_submit/56' method='POST' enctype='multipart/form-data'>
<table border=0 cellspacing=0 cellpadding=3 width='100%' class='webform'>
<tr valign='top' class='optional'>
<td colspan='4'><p class='body'><strong>Contact Information</strong></p></td>
</tr>
<tr valign='top' class='required'>
<td colspan="2"><span class='body'>Name of person requesting equipment</span> </td>
<td colspan="2"><input type='text' name='Name of person requesting equipment' size=35></td>
</tr>
<tr valign='top' class='required'>
<td colspan="2"><span class='body'>Location city and state</span> </td>
<td colspan="2"><input type='text' name='Location city and state' size=35></td>
</tr>
<tr valign='top' class='required'>
<td colspan="2"><span class='body'>Facility name</span> </td>
<td colspan="2"><input type='text' name='Facility name' size=35></td>
</tr>
<tr valign='top' class='required'>
<td colspan="2"><span class='body'>Facility General Manager</span> </td>
<td colspan="2"><input type='text' name='Facility General Manager' size=35></td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"><span class='body'>Shipping address (if different
than location address)</span> </td>
<td colspan="2"><input type='text' name='Shipping address (if different than location address)' size=35></td>
</tr>
<tr valign='top' class='optional'>
<td colspan="4"><hr size='1'/></td>
</tr>
<tr valign='top' class='optional'>
<td colspan="4"><strong>Select the items and quantity below:</strong></td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"><span class='body'><strong>Dell Desktop PC (Kenco-Desktop)</strong></span><strong> </strong></td>
<td colspan="2"><select name='Dell Desktop PC (Kenco-Desktop)' size=1>
<option value='0'>0</option>
<option value='1'>1</option>
<option value='2'>2</option>
<option value='3'>3</option>
<option value='4'>4</option>
<option value='5'>5</option>
<option value='6'>6</option>
<option value='7'>7</option>
<option value='8'>8</option>
<option value='9'>9</option>
<option value='10'>10</option>
</select></td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"><strong>Please provide username and status for each
computer ordered or use N/A if information not known.</strong> </td>
<td colspan="2"> </td>
</tr>
<tr valign='top' class='optional'>
<td width="9%">Username</td>
<td width="35%"><input type='text' name='User Name(s)2' size=35></td>
<td width="10%"><input name='New' type='checkbox' id="New" value='checked'>
<span class='body'>New</span> </td>
<td width="46%"><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"><span class='body'><strong>Dell standard laptop with
docking station (Kenco-Laptop1)</strong></span><strong> </strong></td>
<td colspan="2"><select name='Dell standard laptop with docking station (Kenco-Laptop1)' size=1>
<option value='0'>0</option>
<option value='1'>1</option>
<option value='2'>2</option>
<option value='3'>3</option>
<option value='4'>4</option>
<option value='5'>5</option>
<option value='6'>6</option>
<option value='7'>7</option>
<option value='8'>8</option>
<option value='9'>9</option>
<option value='10'>10</option>
</select></td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td>Username</td>
<td><input type='text' name='User Name(s)2' size=35></td>
<td><input name='New' type='checkbox' id="New" value='checked'> <span class='body'>New</span>
</td>
<td><input type='checkbox' name='Replace existing equipment' value='checked'>
<span class='body'>Replace existing equipment</span> </td>
</tr>
<tr valign='top' class='optional'>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr valign='top' class='optional'>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr valign='top' class='optional'>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr valign='top' class='optional'>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr valign='top' class='optional'>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
<tr valign='top' class='optional'>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
</table>
</form>
</p>
</p>
</td>
</tr>
</table>
<table border="0" cellspacing="0" cellpadding="6" width="94%" align="center" class="sublevel-links-table">
<tr>
<td align="center">
<a href="/www/docs/311" class="stdlink">IT Tools and Templates</a>
</td>
</tr>
<tr>
<td> </td>
</tr>
</table>
<p class="bodycopy" align="center"> </p>
</body>
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