VCUHS Communication Center
Post Office Box 980460
Richmond, Va. 23298-0460
Phone 828-0957 / Fax 628-4402
PAGER REQUEST FORM

 TYPE:
_________ New Account

________ Add On

________ Delete

________ Exchange

________ Loaner

Today’s Date:______/______/______

Telepage Agent: _________________________________

USER INFORMATION (MUST BE FILLED OUT COMPLETELY)                3 Digit MAS Code:_____________________

 Authorization:____________________________________________  (Administrator, Supervisor, etc....)

 User Name:________________________________________________ Employee Number:_____________________________

 Phone Number:____________________ Fax Number:___________________ Box Number:______________________________

 Department Name:_______________________________________ Title:__________________________________________

 Location:____________________________________________________________________________________________________

By signing for this pager I certify that I am authorized to do so by my department and, that I understand that I am personally liable for any charges resulting from a lost or stolen pager or, a pager deemed damaged beyond repair by MCVH. I also understand that if the pager is found within 7 days of being lost, that I will be entitled to a full refund of the lost pager fee ($38.00 numeric, $99.00 alpha).

Signature: ________________________________________ (Print Name)_________________________________________

PAGER INFORMATION
PAGER TYPE:
 Alpha
 Numeric Arch Aquis

COVERAGE:
 Local (In House)
 Extended (Va. Beach-Roanoke, Fredricksburg-N.C. Border)
 Other (Explain):

PAGER # & CAPCODE

Capcode (New): ______________________________

Capcode (Returned): __________________________

Pager Number: ______________________________

Four Digit ID (Local): _________________________

Reason for Exchange: _________________________
LOANER PAGER: Date: ______/_______/_____ Time: ___________ (AM /PM) Agent: ________________
Borrowers Name: _____________________________ 4 Digit ID: __________ Dept.:_____________________

Type of pager: _________Digital ________Alpha Reason for loan:_______________________________

Loaner Pager: Capcode:_____________________

I understand that the pager being assigned is a 24 hour loaner & must be returned promptly. If I or someone from my department does not return this pager within 48 hours, the pager will be deactivated.
Employee Signature:_________________________________________________________________________

Date Returned:______/______/______ Time Returned:____________ Pager Condition: Excellent Good Fair Poor
Agent Accepting Return:___________________________________________________