GOT-F 180 V
VIDEO SITE
INSTALLATION/CHANGE
Governor's Office for Technology
 
CUSTOMER INFORMATION
Date: 
1. GOT Billing #: 
2. Agency: 
3. Customer Name: 
4. Customer Email: 
5. Customer Phone #:  (Example: (800)555-1234)
 
REQUEST
 
6. Type of Request (Check applicable boxes)
 

NOTE: ONLY A NEW video installation also requires completion of items 1-9 & 15 of a GOT F-180 Procurement Request. New installations require signature by authorized Agency Contacts on the GOT F-180 Procurement Request. Electronic signatures are not recognized at this time.

New Video Installation
Move Existing Video Location
Data Needed
Cost Estimate for Video Connection to ATM Network
T-1 Extended
  Note: the Video Equipment State Price Contract Vendor will supply a separate cost estimate.
7. Proposed/Present Video Site Location (Street, Building, Room Number):
 
8. Video Site Contact Name:
  Video Site Contact Phone Number:
  Video Site Contact Email Address:
 
9. Existing Circuit ID# (if known):
 
10. Comments: