IT Communication Services Mobile Device Request Form Section 1: Employee Information
First Name:
Last Name:
Job Title:
_A_Number:
Department:
_Phone Extension:
Department Head:
Building & Room Number
Email Address:
FOAPAL: Fund
Organization
Account
Program
Contact Person: First Name ______________________ Last Name:_________________ Phone Number: ____________________
Section 2: Justification (check all that apply)
Job function requires continuous accessibility beyond scheduled or normal working hours (i.e., on call responsibilities for critical
AAMU services).
Job function requires access to email outside of the office or beyond normal scheduled working hours, and it is essential that the
employee has the ability to receive and send email during those times.
Job function requires the frequent and continuing use of a mobile device on a daily basis during and after hours.
Section 3: Device and Services Preferences (check all that apply)
Voice Only Plan
Voice, Text & Data Plan
Data Plan only
Aircard Device
Samsung Galaxy S4
MiFi/JetPack Device
iPhone 5s
Samsung Galaxy S5
iPhone 5c
Section 4: Approvals
I understand that by submitting this form I am requesting cellular telephone services from Alabama A&M University and that I agree to be bound
by all provisions of the University’s Cell Phone and Wireless Communications policies and procedures listed in Procedure 5.3 Cellular and Mobile
Device Procedures. NOTE: Each Department is responsible for all monthly mobile device charges and equipment (chargers, cases, etc.) accrued
by persons in the department granted mobile devices.
(Requestor- Signature)
(Date)
(Department Head/Chair- Signature)
(Budget Manager- Signature)
(Date)
(Budget Manager- Print)
(Executive Vice President- Signature)
(Date)
(Date)
Please fax signed form to 256-372-8355 or deliver to Patton Hall, Room 317.
IT Communication Services Use Only
Service Start Date:
IMEI #
Cell Device Number:___________________________
MiFi/Aircard Number:
Communications Services Representative: _____________________________ Date Completed: ___________