Please verify the Item Control Number
* Item Control Number:
College/University Information
* College/University Name:
* Department Name:
* Department Head Name:
Applicant's Information
* First Name: Middle Init.: * Last Name:
* Address:
Address 2:
Building:
* City: * State: * Zip:
* Telephone Number: (###) ###-####
Fax Number: (###) ###-####
* E-mail Address :
Grantee/Customer is required to pay Shipping Cost
* 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 ERLE Program in the last 3 years:
* Do you agree with the following Department's Certifications
ERLE Guidelines No Yes
Drug-Free Certification No Yes
