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12/05/11 DOC ID: SMD/FRM-IMG-240B REV. 00 EFF. DATE: 12/15/11 APPROVAL: MGMT. REP. ON FILE
Customer
New Item Request Form
Manufacturer/Brand: ________________________________________________________ Product Name: ___________________________________________________________ Vendor Catalog Number: __________________________________________________ Source/Vendor: __________________________________________________________ Description: ______________________________________________________________ Unit of Issue (box, case, each, etc): ___________________________________________ Price per Unit of Issue: _____________________________________________________ Estimated Monthly Usage: _________________________________________________ Estimated Monthly Demand: _______________________________________________ Email: ___________________________________________________________________ Phone: ___________________________________________________________________ IC and Bldg/Rm No: _______________________________________________________ User Name: ______________________________________________________________ Signature: _______________________________________________________________