Space Request Form

Space Request

Date of Request: *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year20162017201820192020

Requesting Department: *

Appointing Authority or Authorized Agent: *

BGS/Vision Customer #: *

Billing Address: *

Coordinator / Contact Person: *

Phone: *

Email: *

Back up Coordinator:

Back Up Phone:

Back Up Email:

Current Location: *

(Town, Building, Floor, Room)

Desired Location: *

Current No. of Positions: *

Anticipated No. of Positions: *

Funding Available for New Space: *

Yes

No

Funding Available for Move/Construction: *

Yes

No

Funding Source: *

(Agency Funded, Capital Construction, Major Maintenance)

Department ID:

Desired Move Date: *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year201820192020

Type of Space Required: *

(office, warehouse, etc.)

Special Requirements: *

(waiting rooms, conference rooms, etc.)

Construction Required: *

Yes

No

Justification & Additional Description *

Authorized Maintenance Connection Users in Your Building: *