* 1. Where do you work (building)?

* 2. Why are you requesting access to this room?

* 3. Name of person requesting access

* 4. At what email address would you like to be contacted?

* 5. At what phone number/pager would you like to be contacted?

6. How many weeks/months will you need access to breast-pumping space?
(please provide your approximate start & end dates as well)

7. What breast-pump do you plan to use?

8. What shift do you work?

9. How many days/week do you work? Are you full time/part time?

10. Thank you for completing this registration form. Once you submit the registration, please call 734-232-4120 to schedule a time to use the room and get the key code to enter. You can leave a voicemail.

Since the room is a multi-purpose room, all users are asked to schedule (this is vital during day-time hours); no-shows or ad-hoc users may lose access to the room. Thank you.

Once you sign up and receive the access code, you will be added to a "read only" email schedule that will allow you to view room reservations.

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