Equipment Request Form
Name
Project
Category
SLA
Requesters First Name
*
Requesters Last Name
*
Requesters Contact Number
*
Please enter a valid phone number.
Format: +440000000000.
Requesters email addresss
*
firstname.surname@birminghamhospice.org.uk
Equipment Requirements
Reason for equipment?
*
Addition to Role
DSE Assessment
Theft
Wear & Tear
Work station setup
What equipment do you need?
Please choose equipment required
*
Please Select
Apple Accessories
Docking Station
DSE Chair (Via Assessment Only)
DSE Keyboard (Via Assessment Only)
DSE Mouse (Via Assessment Only)
DSE Wrist Rest (Via Assessment Only)
Headphones
Keyboard
Keyboard
Laptop
Laptop Bag
Laptop Trolly
Mobile Phone
Mobile Phone Charger
Monitor
Mouse
Power Supplies
Printer
Smartcard Reader
Web Cam
Please specify the reason for the equipment request
*
Request Date and Time for the equipment to be delivered:
*
Where is. the equipment needed?
*
Erdington
Selly Park
Remote/Home Setup
Retail Shop
Retail shop address:
1st Line of your address:
*
House/ Apt Number and Street Name
City:
*
Which City is this?
Postcode:
*
Whats the postcode
Employee Details
(Enter the details of the person receiving the equipment)
Name
*
First Name
Last Name
Role
*
Department
*
Line Managers Details
(Enter the details of the person who line manages the Employee receiving the equipment)
Line Managers Name
*
First Name
Last Name
Date
Line Manager Email address:
*
firstname.surname@birminghamhospice.org.uk
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