Laboratory Equipment Donation Program

Application

Please verify the Item Control Number and the Equipment Name. Please do not leave any required field blank; if no information is available, enter an "X". * denotes required fields.
Item Control Number:
Equipment Name:
School Information
*School Name:
*Department Name:
*Department Head Name:
Applicant's Information
*First Name:
Middle Initial:
*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:
Shipping 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 GuidelinesNo Yes Drug-Free CertificationNo Yes

Last Modified: 01/30/2013

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