Teleresvform2000a

RESERVATION FORM

USDA GEORGE WASHINGTON CARVER

TELEWORK CENTER

PLEASE COMPLETE THIS FORM AND RETURN IT TO THE TELEWORK CENTER BY E-MAIL TO GWCTELEWORK@USDA.GOV or fax to (301) 504-3678. Questions? Call (301) 504-3783.
Employee (individual) workstations can be reserved for a day, week, or for the same day(s) each week for the entire fiscal year.
Please print or type
NAME First
Middle Initial
Last
Nickname
Office Phone No. (_ _ _) _ _ _-_ _ _ _ ext._ _ _ _
Office Fax. No. (_ _ _) _ _ _-_ _ _ _
Office E-mail Address
Occupation (Title)
Occupation (Grade/series) Series(GS) _ _ _ _ _ _ _Grade _ _ _ _
Agency USDA, _ _ _ _ _ _ _ _ _ _ _ _ _ _ Non-USDA, __________
SPECIAL NEEDS

(accommodations for disabled)

NO; Yes (If yes please enter need)
LAPTOP STATION

(no computer provided)

YES NO

What NETWORK is your E-Mail on?
Computer Support Contact
WORK ADDRESS

Building

Mailing Code/

Room Number

Street Address
City
State
Zip Code _ _ _ _ _ - _ _ _ _
Supervisor's Name
Supervisor's Phone No. (_ _ _) _ _ _-_ _ _ _ ext. _ _ _ _
Day(s) Pay Period - Week one Mon Tues Wed Thur Fri WEEK(ALL)
Week two Mon Tues Wed Thur Fri WEEK(ALL)
Start Date (MM/DD/YY) _ _/ _ _/ _ _
Stop Date (MM/DD/YY) _ _/ _ _/ _ _ FY Indefinite
If you entered FY above, do will you want to continue working at the Center next FY?



Yes No
EMERGENCY CONTACT

Name

Phone (_ _ _) _ _ _-_ _ _ _ ext. _ _ _ _
Beeper/Pager (or Cell Phone) (_ _ _) _ _ _-_ _ _ _ pin _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Alternate - Name
Phone (_ _ _) _ _ _-_ _ _ _ ext. _ _ _ _
Beeper (or Cell) (_ _ _) _ _ _-_ _ _ _ pin. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
HOME

Phone Number

(_ _ _) _ _ _-_ _ _ _ ext. _ _ _ _

(this info. is requested to notify you of any emergency cancellations)

Address (Street)
City
State
Zip Code _ _ _ _ _ - _ _ _ _
WORKSTATION # preference
Today's Date
Special Health Needs If you have special health concerns please advise the nurse at the facility when you start working at the Center. The Health Unit's phone number is 504-2398.

Please submit a copy of your signed Employee/Supervisor Agreement & Employee/Supervisor Checklist to the Center Manager along with this completed registration form prior to using the Center.


RESERVATION FORM

TASK FORCE SUITE

GEORGE WASHINGTON CARVER

TELEWORK CENTER

5601 Sunnyside Avenue

Beltsville, Maryland 20705

"The Task/Telework" suite can be reserved for short term task forces (not to exceed 90 days). It is set up to accommodate 12 persons, including a private office for the head of the task force and a administrative/clerical station. An additional two laptop workstations are available for use in the Task/Telework suite.



The workstations in this room are available for use by individual employees with the understanding that if the Suite is needed for a Task Force, all reservations for these workstations will be cancelled.

CONTACT NAME First
Middle Initial
Last
Office Phone No. (_ _ _) _ _ _-_ _ _ _ ext._ _ _ _
Office Fax. No. (_ _ _) _ _ _-_ _ _ _
Office E-mail Address
Occupation (Title)
Occupation (Grade/series) Series(GS) _ _ _ _ _ _ _Grade _ _ _ _
Agency USDA, _ _ _ _ _ _ _ _ _ _ _ _ _ _
TASK FORCE NAME
Justification for (or Mission of Task Force)
Number of Persons in task force 5 6 7 8 9 10 11 12 13 14
Day(s) Needed Mon Tues Wed Thur Fri WEEK(ALL)
Start Date (MM/DD/YY) _ _/ _ _/ _ _
Stop Date (MM/DD/YY) _ _/ _ _/ _ _ (Maximum 90 days from start date)
Note: A task force may be required to temporarily relinquish use of the George Washington Carver Center space if an emergency situation arises requiring official use of the space by the Department.