Fiscal and Physical Resources Request Form

Please complete the following form for EACH item that you are requesting. Submission deadline is February 1. Please note that if ordering information is not complete upon submission, the item will NOT be considered for prioritization or purchase.

 

Requestor Information:

First Name:
Last Name:
Course #:
KSU Extension:
KSU Email:
Location:
Is this a rerequest?

 

Description and Justification:

 

Vendor Information:

Vendor Name:
Vendor Address:
Vendor Phone #:
Vendor Fax #:
Vendor Email:

 

Requested Item Information:

Item Name:
Item Cost:
# of Items:
Total Cost:
Catalog Name:
Catalog Page #:

 

This request relates mostly to: (Choose the one that fits best)

BSN Program Research
MSN Program Nursing Skills Lab
DNS Program Events
Other  

 

Approximate Cost (for total expenditure):

Under $100 $101-$499
$500-$999 Over $1000
Unable to determine  

 

Date needed:

 

Other Comments: