First Name:                                                                         Department Name:

                                

    Last Name:                                                                          Building Name:

                                

    Title:                                                                                    Room Number:

                                

    ETSU E-mail Address:                                                        Phone Number:

                                

              List ETSU Departmental Index Number(s) you will use to charge shipment cost:

              Please fill out form, print and obtain appropriate signatures.  Fax this completed form to

              Central Receiving at 439-5793.  Please remember that once this account is created, you

              are liable for all shipping charges under your given user name and password.  It is

              recommended that you keep your user name and password in a secure location and

              change your password frequently.  Central Receiving will not be responsible if

              unauthorized packages are shipped using your account.          

              ______________________________        _______________________________

              Shippers Signature                Date                 Department Head                  Date

              For Office Use Only

              _____________________________________        ____________________

              Account Created By                                                   Date