First Name:
Last Name:
Location: ( e.g. Nursing Unit )
Room No:
Telephone:
Date of Departure:
Email Address:
Primary Use:
Internet
Email
Other
** If select other, please specify **
Operating System:
PC - Windows 98
PC - Windows 2000
PC - Windows XP
MAC - OS 9
MAC - OS X
Other
** If select other, please specify **
Hardware Address of Network Card:
-
-
-
-
-
Additional Comments:
