UCSF New Furniture Request Form THIS FORM IS USED FOR NEW FURNITURE REQUESTS, RECONFIGURATION OF SPACES, AND GENERAL FURNITURE RELATED INQUIRIES. NOTE: all areas with an asterisk * must be completed in order to process this request. Please submit one form per location/project.Date* MM slash DD slash YYYY Submitted by* Email Address* Phone Number* LOCATION OF WORK TO BE PERFORMEDCompany Name* Customer OWP Account Number* Street Address*Please select an address...1825 4th Street - MB Gateway and PCMB1855 4th Street - MB Women's and Cancer Hospital1975 4th Street - MB Children's HospitalOther Mission Bay address (please note below)Parnassus (please note address below)Mt Zion (please note address below)Other (please note below)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Department* Station/Room Number* Contact Name* Contact Phone Number* Alternate Contact Name* Alternate Contact Phone Number* LIST OF AVAILABLE SERVICESPlease submit one form per request.Please check as many as applicable New Product Request Minor Furniture Adjustments Furniture Reconfigure/Changes to Layout Damaged Product/Warranty Request Please leave a detailed description of work to be performed.*You selected an issue that requires repair/replacement. Please provide (3) photos of the issue: an overall picture to identify the product, a clear picture of the damage and a picture of the manufacturer's label (often located underneath chair or work surface or inside of a drawer).You selected a request for new product. If you would like to re-order existing product, please provide the original order number below. If not available, please provide a photo to identify the product.You selected a request for Furniture Reconfigure/Change to Layout. In some instances, your request may require design services at $75.00/hr. and your approval to proceed.Picture to Identify Product*Max. file size: 100 MB.Picture of Damage*Max. file size: 100 MB.Picture of the Manufacturer Label*Max. file size: 100 MB.Upload reference photo (if available)Max. file size: 100 MB.NOTE: Parts (if required) can take approximately 3.5 weeks to 4.5 weeks depending on vendor. Minimum Service is 3 hours at $102.00 per hour (prevailing wage requirement of UCSF). Non warranty items will be billed.