University of Connecticut Health CenterOffice of Logistics Management (OLM)
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                                 MAIL SERVICE REQUEST - LM-18

MAIL ENTIRE PACKAGE TO:      Mail Center,  Building J,   MC 0999                                              Phone:   679-2858 
NAME:    
BUILDING: FLOOR: ROOM  #:      TEL. #:      
DEPARTMENT:
MAIL CODE:  MC         E-MAIL: 

                                                   Parcel Information - Must Be Completed
UConn Health Related:  Yes    No     (Check One)

Description of Contents:
                                          Example:  Invitations, Flyers, Notices, Marketing Material, etc.

Service Requested

  To Be Completed by Mail Center


Priority Mail & First Class:  Quantity  

Express Mail:  Quantity  

Bulk/Third Class:  Quantity  

Other Mailing: Quantity  
 
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 Coding:  Fiscal Year:   Fund:   Org:    Program:   Account:   Amount:  

AUTHORIZED SIGNATURES

___________________________________
1. DEPARTMENT HEAD  (PRINT)		 ________________________________
1.    AUTHORIZED SIGNATURE		 _______
DATE

MC USE ONLY

RECEIVED BY:     
INITIALS: ________ 
TIME: ________  
DATE:  __________		 REQUEST IS: 
APPROVED:   
DENIED:       		 PICK-UP DATE: 

 ____________		 COMPLETED BY:   
INITIALS: ________ 
TIME: ________    
DATE:  __________

                               MAKE A COPY FOR YOUR FILE

IF YOU NEED ASSISTANCE COMPLETING THIS FORM, CALL 679-2858    REFERENCE # M

LM-18   Revision 10/12/15