REQUESTOR INFORMATION. (This Section Must Be Completed. Each blank space in this Part must be completed. If you do not provide information for a space, you must write "N/A" for "not applicable".)
REQUESTOR INFORMATION. Initiator of Request Name ( Mobile Position e-mail Fax Prime Contact (if different from Requestor) Name ( Mobile Commercial in Confidence Page 57 May 2004 Position e-mail Fax Project Manager1 Name ( Mobile
REQUESTOR INFORMATION. 3a. Bureau/Office 3b. Organization 3c. Address (City, State, ZIP) 3d. Delivery Address (City, State, ZIP) 3e. Contact Name 3f. Email 3g. Phone 3h. Fax 3i. Authorizing Official (Name & Title) 3j. Signature
REQUESTOR INFORMATION. 3a. Bureau/Office 3b. Organization 3c. Address (City, State, ZIP) 3d. Delivery Address (City, State, ZIP) 3e. Contact Name 3f. Email 3g. Phone 3h. Fax 3i. Authorizing Official (Name & Title) 3j. Signature 4a. Type of Request New Installation Replacement (Complete Block 6) 4b. Type of Acquisition Purchase Cost Per Copy Operating Lease Rental 4c. MFD Bundle Plan A: Copy/Print B: Copy/Print/Scan C: Copy/Print/Scan/Fax 4d. Vendor and Equipment Selection Vendor Model Volume Band (VB) Print Output: Black & White Color 4e. Basis for Selection. If Price or Plan Sole Source is checked, skip Block 5 Price Plan Sole Source If selection is based on criteria other than Price/Plan Sole Source, then select all items below that apply and complete Block 5 Justification: Special Features Trade-in Service Response Maintenance Availability Past Performance Plan Continuity or Modification Other Considerations
REQUESTOR INFORMATION. This section of the form includes: Requested By; Phone Number; Email Address. This section of the form lists all WorkSource Centers and also includes: 1) Other Office Location; 2) Program.
REQUESTOR INFORMATION. 1. Applicant County XXXXXXX 2. Federal Employer ID Number 00-0000000 3. Fiscal October 1, 2018, to September 30, 2019
REQUESTOR INFORMATION. Provide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this form. Last Name: First Name: Middle Initial: Address: Suite Number: City: Province: Postal Code: Country: Phone Number: Email Address (if available):
REQUESTOR INFORMATION. 1.1 - REQUESTOR INFORMATION ---------------------------------------------------------------------------------------------------------------------------- COMPANY NAME: ---------------------------------------------------------------------------------------------------------------------------- REPRESENTED BY (NAME, POSITION): ---------------------------------------------------------------------------------------------------------------------------- ADDRESS: ---------------------------------------------------------------------------------------------------------------------------- CITY: ---------------------------------------------------------------------------------------------------------------------------- COUNTRY: ---------------------------------------------------------------------------------------------------------------------------- POSTAL / ZIP CODE ---------------------------------------------------------------------------------------------------------------------------- PHONE NUMBER: ---------------------------------------------------------------------------------------------------------------------------- FAX: ---------------------------------------------------------------------------------------------------------------------------- N(DEGREE) SIRET: ---------------------------------------------------------------------------------------------------------------------------- CODE NAF: ---------------------------------------------------------------------------------------------------------------------------- BILLING ACCOUNT (IF IT IS THE CASE): ----------------------------------------------------------------------------------------------------------------------------
REQUESTOR INFORMATION
