Please verify the Item Control Number

* Item Control Number:

* School Name:

* Department Name:          

* Department Head Name: 

* First Name:     Middle Init.:    * Last Name:

* Address:    

Address 2:              

Building:       

* City:             * State:       * Zip:

* Telephone Number:                (###) ###-####

Fax Number:                           (###) ###-####

* E-mail Address:               

* Method of Shipment:  

Account Number:         

Purchase Order:          

* Shipping Address:   

Address 2:                 

* City, State, & Zip:    

* Description of how equipment will be used:

* Description of any equipment granted by the LEDP Program in the last 3 years:

* Do you agree with the following Department's Certifications

            LEDP Guidelines                                               No Yes

            Drug-Free Certification                                     No Yes