TYPE OF EQUIPMENT DESIRED _______________________________________

__________________________________________________________________

WILLING TO PAY (Yes/No)________

REQUESTING DONATIONS ________________

NAME OF AGENCY/COMPANY ________________________________________

ADDRESS ________________________________________________________

CONTACT NAME/TITLE ______________________________________________

PHONE NUMBER/S _________________________________________________

FAX NUMBER ___________________________

TYPE OF AGENCY/COMPANY ________________________________________

FORM (explain): ____________________________________________________

GOVERNMENT _____ NOT-FOR-PROFIT_____OTHER _____

MISSION OF AGENCY _______________________________________________

OTHER COMMENTS:________________________________________________

RETURN TO:

LINDA BROWN

PURCHASING AGENT