Missouri State University

Utility Interruption Form

Date: _____________

 

Missouri State University
Utility Interruption Sheet

 

Date of Outage: _______________________

Start Time:        ________________________

End Time:         ________________________

Requester Fill Out Lower Section Only

----------------------------------------------------------------------------------------------------------------------------------------

Effected Buildings:  ______________________________________________________

Contact Person:        _______________________________________________________   

Reason for Outage:  _______________________________________________________   

Utility Type/Types:  _______________________________________________________________

Number of Hours Needed:  _________________________________________________

Services Effected:    ________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Preferred Date & Time:  ____________________________________________________

Start Time:                  ______________________________________________________

Please fill out above and fax this form to the Work Management Center @ 65288

Please give us a two week notice.

Date: __________                     Approved                                     Disapproved