KEEP A COPY FOR YOUR RECORDS AND FORWARD COPIES TO:

1. 1. YOUR OBLIGATING/PAYING OFFICE

2. 2. GSA: Attn: Penny Einarsen, Room 4333 Business Performance, F Street Washington, DC 20405

3. 3. Telecenter Director

1. Enter Date of request.
2. Leave Control Number Block Blank GSA Use Only
3. Enter name of Agency requesting telecenter use.
4. Enter telecenter location name & building #:

5a-e. Enter information regarding the individual responsible for agency employee(s) telecenter coordination. Enter a concise statement of workstation used, fees and total projected monthly costs.

7. Check if new information sheet.

8. Check if submittal is a modification to an existing AGREEMENT or information sheet.

9a. Enter billing type: C = Credit Card

9b. Enter billing terms: A = Advance, C = At completion, M = Monthly, Q = Quarterly, T = At Termination, Y = Annually (in arrears),

10a-b. Enter agreed upon project start and completion dates.

11. Enter the total dollar amount approved for funding. Must match GSA=s established telecenter fees.

12a. Enter the eight (8) character agency location code. (Treasury Pay-station Designator)

12b. Enter the appropriate agency identification number.

12c. Enter the appropriate agency fund code.

12d. Enter agency accounting information (Limited to 60 characters).

13a. Enter the agency Fed Code. 13b. Enter the agency bureau code.

14a-d. Enter the appropriate billing address information.

15a-c. Enter signature, name and date of agency's authorized representative, certifying the validity of order and the availability of funds.

16a. Enter Credit Card Number (Or phone the appropriate GSA official with this information.

16b. Enter expiration date

16c. Enter type of Card.

16d. Enter Card Holder=s name.

17. Enter the certifying official's phone number.

18. Telecenter Director signs here when user vacates workstation.

Enter the Point of Sale Terminal (For Credit Card Purchases Only).