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:

THIS FORM FOR MEDICAL AREA ONLY: PRINT THIS SHEET, FILL IT OUT AND FAX TO 5-6948
A cover sheet is not necessary.

YOUR NAME:____________________________________________________________________________

YOUR DEPARTMENT: _____________________________________________________________________

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

NEW ADDRESS: ____________________________________________ ROOM #:_____________________

ANTICIPATED DATE OF MOVE: _____________________________________________________________

PERMANENT MOVE ____ or TEMPORARY MOVE UNTIL _________________________________________

Do you currently receive via e-mail the weekly Mail Tips: (please check) yes_____ . no _____
If no, to add your name, print your e-mail address: _______________________________________________________

Additional information we should be aware of regarding your move:__________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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

TELEPHONE #: ________________________________________________

EMAIL ADDRESS: ______________________________________________