Equipment Repair Request Biological Sciences

All fields marked with an asterisk * are required

Person Placing Request:*

Lab Association:*

Phone Number:*

Email Address: *

Is this an Emergency?

Yes     No

Type of Equipment:*

Brand of Equipment:*

Model Number:*

Serial Number:*

Room Number:*

Building:*

SES  MBRB  SEL

Other:

UIC Tag Number (if known)

Description of Problem (please be as detailed as possible:

Account to Charge to:

                           

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