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MLTI Dial-Up Modem Request Form

If a modem is needed, please ensure that the Tech Lead at the school completes this form. Modems will be shipped directly to the Tech Lead listed in the Asset Manager.


Please find paperwork for free internet access here.


If you are a teacher, parent or student, please contact your school's Tech Lead to see if they have any modems on hand. If not, the school's Tech Lead can complete the form. If you are unsure who holds the Tech Lead role at the school, the principal's office will have that information.


Modem Request Form


* Indicates a required field.


Requestor Information:

First Name*


Last Name*






Today's Date* (mm/dd/yyyy)



School Information:

If your school is not in the list, please select Other and put your school name & school code in the following text box:


How many modems?




** Each field requires an answer, so please use a 0 if the field does NOT apply to you.


Please do not include teachers who already have one of the modems that were issued to them through the 2007 High School Teacher Program. They will not need a new modem.




Once you have completed this request form, please hit submit. Your request will immediately be emailed to the MLTI Project Office.





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