Pager Information Sheet
The following information is needed to issue a pager.  This information will be placed in a database for the Telephone Operators. You must indicate any information that is private and not to be given out.
Required information will be indicated by an asterisk *
Before a pager can be issued, send form to GME Office (AE 3042) for signature and cost center account number. GME Office will forward request to Telecommunications when approved. 
Person submitting this request *      	
Contact Number *work ext.      	
Business Unit Manager      	
VP Signature      	
Name of the person the pager is for* First and Last Name	
Title / Position (ex. Faculty, Resident, Director, Manager, Nurse)	
Cost Center  (Account Number) * GME Office will fill in	
Business Unit (Department Name) * Program Name	
Location / Address (Example BA 4200)	
Contact Numbers 
Work *      	
HOME *      		MUST HAVE FOR DATA BASE BACKUP
Cell      		Private	 YES or  NO 
Type of pager requested
 Wide Area Pager @ $ 8.30 - Coverage Area - 75% of GA, 98% of SC, and 20% of NC
 Premise Pager @ $ 6.30 - Coverage Area – Within the hospital
 Nation-Wide @ $ 25.30
Pager Number Requested      	
Please note that we will work to provide the requested number – if it is not available we will assign an available number.