Requester: __________________________________________________________

Telephone: __________________________ Building/Office#: __________________

E-Mail Address: ______________________________

How many students will use this application: ________________________________

Department/College: __________________________________________________

Chair: ________________________________ E-Mail: ______________________

Name of Software Package: ___________________________________________

Company: _____________________________________________

Company Contact: ______________________________________

NOTE: This form must be accompanied by a complete set of working diskettes. If documentation/manuals are available, they are to be forwarded with this document. Print out this form and complete. Forward diskettes and documentation/manuals/license via campus mail to: Academic Computing - Dempsey Hall