Designer

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					                                                           OCR use only
                                           Designer:
                                           Work load: Options
                                           Tracker No.:

                                 1001 Forms Design and Printing Request
                        Fill out the form, print and FAX or send electronically via e-mail.
E-mail to OCR at: dhs.forms@state.or.us                                                     FAX to: 503-373-7690
       Date:              Contact name:                                                     Phone:
      Section 1




                  Program/unit:                                                       Do you want a quote?         Yes      No
                  Billing information: Agency No.                      Index:                       PCA:
                  Billing address/contact:
                  Form number:                                        Last revision date:
                  Project name:
                  Design due date:                                    Policy implementation date:
      Section 2




                  Final completion date:                              Document type: Click arrow to select
                  Job type: Click arrow to select                     If obsolete, what is replacing.
                  This project is: Click arrow to select     Other:
                  If printed – Quantity:                                 Shrink wrap quantity:
                  Electronic formats: Click arrow for word options and/or Click arrow for pdf options
                  Service:         Create        Revise          Obsolete          Post only        Print only
      Section 3




                  Old Stock:       Recycle       Use             Shred             Other: (Specify):
                  Translate:       Spanish       Russian         Vietnamese          Somali
                                   Other (Specify):
                  Alternate format: Type: Click on arrow to select        Language:
                  Deliver materials to:           Distribution center              Distribute/production mail
Section 4




              A
                     Unit (Specify address in “other”)          Other (Specify):
                  Internet: OCR forms server?          Yes       No        Link to a policy      Link to another web page
              B
                  Provide web link and/or contact name:
                  Printing or special instructions:
      Section 5




                     Mailings – Provide name of person supplying data information:



                    * Color exception letter attached (required for any and all color printing requests).
                  NOTE: Signature not needed if sent electronically with authorized e-mail (please print name
      Section 6




                  and date).  Attached          Signature(s) authorized to spend funds



                  Signature(s)                                Print name(s)                                      Date

                                                                                                                 DHS 1001 (1/11)

				
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