Science Center Equipment Request Form Phone Department/Program/Center * Astronomy Biochemistry Biological Sciences CABR (Center for Aqueous Biogeochemical Research) Center for Proteomics Chemistry CMI (Center for Microscopy & Imaging) CMB (Center for Molecular Biology) Computer Science Engineering Environmental Science and Policy Geosciences Mathematics and Statistics Neuroscience Physics Psychology Statistical and Data Sciences Point of Contact for this Request * Email Address for Point of Contact * The academic year you are requesting to make the purchase * 2019-2020 2020-2021 2021-2022 After 2022 Equipment or System Name * Description * For what class or classes is this equipment required? Please indicate dept/prog, course number and title. Which TT (tenure track) faculty members REQUIRE this equipment? Which TT (tenure track) faculty members would/could use this equipment if we had it? How many undergraduates will use this system HANDS-ON in a given year? Please choose the best description for the purpose of this request * Replacement for unusable equipment Replacement for end-of-life but still functioning equipment State-of-the-art replacement for obsolete equipment Replacement for equipment chronically needing repair Enhancement to existing equipment that will expand usage New technology we have not had Other, please specify How many proposals for external funding were submitted but not granted? * 0 1 2 3 Greater than 3 Who will manage the equipment? * Where will the equipment be located? Building * Bass Burton Ford McConnell Sabin Reed Other If you selected other above, please specify the location. Room Number * Who will pay for consumable supplies? Expected Total Cost Including required accessories, shipping, and installation * Department/Program/Other Cost Share Value of Trade In Discount Negotiated, if any Total Amount Requested from Science Center Equipment Fund Total:$ This field calculates automatically Is there anything else you'd like us to know about this request? A copy of your submission will be sent to the email address for the point of contact entered above. You will be redirected to the form again to make additional requests if you need to.