1.	Requested activity:
	Activation  Deactivation   Other, please specify

2.	Requester's name:

3.	Requester's phone:

4.	Requester's e-mail:

5.	Requesting department:

6.	Port location building:

7.	Port location room number:

8.	Port usage:
	Faculty  Non-faculty  Student use only   Other, please specify

9.	Index number to be charged:
	Index # Installation charges:   Monthly charges:

10.	Today's date:

11.	Date of activation (if different from today):

12.	Period of activation time required (if applicable):

13.	Other comments: