Facilities Work Request
If an URGENT maintenance need, please call: extension 5538
Email completed form to: Workrequest@blm.gov
Is the work: REPAIR of EXISTING, Complete Part A
(Check One) NEW WORK, Complete Part A and B
Budget: $
Approving Official:
Part A:
Requestor Information:
Date Submitted:
Date Required:
Building #/Name:
Room #/Location:
Summary of request:
Part B:
Requester’s estimated budget (confirmed):
Number of FTE (non-telework) workstations:
Number of Telework Employees:
Number of spaces for Kiosk Hoteliers:
Other personnel/agencies affected by request:
Standard Equipment Needs:
Fax(s): Printer(s): Plotter(s): TV(s):
Specialty Equipment Needs:
NIFC Form 9100-2
Page 1 of 2
(Revised) September 2019
AV: Vertical Storage: Security Door: Other:
Facilities Department use only:
Facilities use only for NEW WORK
HVAC: IT/Phone: Power/Electrical: Security:
Carpet: Paint: Lighting: Ceiling:
NIFC approving official for change of Area Assigned to Agency:
Signature of Division Chief of Support Services Date
Facilities use only for REPAIR of EXISTING:
Assigned to:
Date Assigned:
Contractor Cost:
Staff Hours spent:
Date Completed:
Cost of Materials:
Comments (5 lines Maximum):
NIFC Form 9100-2
Page 2 of 2
(Revised) September 2019
click to sign
click to edit