Pager #_________ S/N _________________ Cap Code ____________ Date______________

Date Issued _______ M/N____________________ Sent to SWBD _______ Printer___Fax___

User Last Name First Name Init

User Nickname User Title Employee ID

Campus Address Zip

Campus Phone Home Phone

If pager will rotate among more than one person, please list all names:

Previous User if Applicable Employee ID

Previous User Pager No Effective Date of Change

Do you wish User's Name and Pager Number to be listed in annual directory? Yes No
Do you wish User's Name and Pager Number to be listed on our Website? Yes No

I understand that the value of a pager is $225.00 and due care must be exercised in its use. Damage
to or loss of the unit will be reported immediately to the UAB Radio Paging Office at 934-2599.
The unit will not be transferred to another department or taken upon termination of employment,
but returned to the Radio Paging Office, 100 Burleson Building, 909 South 18th Street, ZIP 4370.

User's Signature ____________________________________________ Date ___________

Dept Financial Official's Signature ____________________________________ Date _________

Type Dept Financial Official's Name & Extension here