Department of Medicine Smartsheet Enterprise License Request

Department of Medicine Smartsheet

Enterprise License Request

Please complete the form below to initiate a request for a DGSOM Smartsheet license.

Requestor Name*

First and last name of individual submitting request.

Requestor Email*

Email address of individual submitting request.

Requestor Division

Please provide division name.

CAO and Division Leader Name*

First and last name of the Division Leader.

CAO and Division Leader Emails*

Email address of the Division Leader.

Unit Quantity*

Please clarify the number of licensed users being requested.

Desired Start Date

Please specify the date you'd like the licenses active and assigned.

Names of Licensed Users*

First and last name of the individual(s) requiring licenses, separated by semicolons.

Emails of Licensed Users*

Email address of the individual(s) requiring licenses, separated by semicolons.

No PHI Attestation*

I attest that no PHI (Protected Health Information) will be contained in Smartsheet, and that this user for whom the license is being requested, is also aware of this restriction.

AP/Invoice Contact Name*

First and last name of the individual responsible for processing payment for the annual subscription cost.

AP/Invoice Contact Email*

Email address of the individual responsible for processing payment for the annual subscription cost.

Desired FAU

Notes

Please provide any additional information as necessary.

File Upload

(Not Required) Attach evidence of DSA and/or Division Leader pre-approval(s) if obtained in advance.

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