Date:

Submitted by (name):

Number:

Email:

School relevance:
(select at least one)

School department/project:

Type of item:
(select at least one)

Name of product:

manufacturer:

model #:

vendor or publisher:

new Number of seats requested:
(also include the lab / location of the install)

Description:
(include costs, etc.)

Current solution:
(Explain what we are currently using if anything, for this need)

Reasons why the current solution is not effective:
(List specific shortcomings)

Courses and competencies served:
(List specific courses, and competencies, cite course numbers, specific competencies from course catalog and syllabus)

Date approved:

Status:

By whom :

Discussion and decision made::