Research Lab Request Form Research Lab Request Form "*" indicates required fields Submitter's InformationIf you need assistance, please contact Mickey Thomas, mickey@uam.eduName * Required First Last Employee ID# * RequiredEmail * Required Phone numberDivision/College * RequiredDepartment * RequiredResearcher's InformationEmployment status of the researcher * Required Current Faculty Incoming Faculty Future Opening – Search in Progress Name * Required First Last Job Title * RequiredDivision/College * RequiredDepartment * RequiredName Of Department Chair * Required First Last Start Date * Required Month Day Year Projected Start Date * Required Month Day Year Projected Start Date * Required Month Day Year Please contact Mickey Thomas at mickey@uams.edu when the position is filled.Funding InformationStart Up Funding? * Required Yes No Source of Start Up Funding * RequiredAmount of Start Up Funding * RequiredPlease enter numbers only in this format 9,999.99Current External Grants ? * Required Yes No First Grant Title * RequiredFirst Grant ID# * RequiredDirect Cost Amount * RequiredPlease enter numbers only in this format 9,999.99First Grant Start Date * Required Month Day Year Is there a second external grant? * Required Yes No Second Grant Title * RequiredSecond Grant ID# * RequiredSecond External Grant Direct Cost Amount * RequiredPlease enter numbers only in this format 9,999.99Second Grant Start Date * Required Month Day Year Is there a third external grant? * Required Yes No Third Grant Title * RequiredThird Grant ID# * RequiredThird External Grant Direct Cost Amount * RequiredPlease enter numbers only in this format 9,999.99Third Grant Start Date * Required Month Day Year Is there a fourth external grant? * Required Yes No Fourth Grant Title * RequiredFourth Grant ID# * RequiredFourth External Grant Direct Cost Amount * RequiredPlease enter numbers only in this format 9,999.99Fourth Grant Start Date * Required Month Day Year Is there a fifth external grant? * Required Yes No Fifth Grant Title * RequiredFifth Grant ID# * RequiredFifth External Grant Direct Cost Amount * RequiredPlease enter numbers only in this format 9,999.99Fifth Grant Start Date * Required Month Day Year Lab specificationsWill modifications be required for this lab? * Required Yes No To be determined. Funding source for modifications * Required Start Up Fund Grant Department Other Other funding source for modifications * RequiredSummary of modifications requirements. Please upload all documents in a single PDF/Word file. * RequiredMax. file size: 15 MB.Please share any pertinent information regarding this space request. Thank you.Examples: collaborators, shared equipment location, special requirements (weight, structural, door width, vibrations, emergency power backup/red outlets), etc. PhoneThis field is for validation purposes and should be left unchanged.
