Medical Area Moves

Help us keep your information current! When you find out when and where you will
be moving to, print out this sheet, complete and fax it to Medical Receiving at
(78)5-6948. We will be able to provide you with package delivery service through
this move if advance notice is given to us. Please provide us with the following
information for each person involved in the move:

YOUR NAME: ____________________________________________________________________________

YOUR DEPARTMENT: _____________________________________________________________________

PRESENT ADDRESS:_______________________________________ MAIL CODE: _______(3-digit number)

NEW ADDRESS: ________________________________________ ROOM #: _____________________

ANTICIPATED DATE OF MOVE: _____________________________________________________________

PERMANENT MOVE ____ or TEMPORARY MOVE UNTIL _________________________________________

In the event of problems with your delivery, please include the following information:

TELEPHONE #: ___________________________________________________________

EMAIL ADDRESS:_________________________________________________________

THIS FORM FOR MEDICAL AREA ONLY:

PRINT THIS SHEET, FILL IT OUT AND FAX TO 5-6948