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)