Needs Request Form

Needs Assessment Purchase Request

Please submit one form per item requested. All requests go directly to the Budget Committee for review and/or approval. Please submit as early as possible.
Description and Justification
Requestor's Name*

First NameLast Name
Facility/Agency*
Please enter you Agency or Facility
Requestor Email*
example@example.com
Requestor Phone/Cell*

Area CodePhone Number
Date Requested*

MonthDayYear
Date
Type of Request*
Quantity requested?*
Number of units
Unit description?*
i.e. each, cases, pallets, gallon etc
~ $ Cost per unit*
Price each plus S&H
Description of request*
Be as descriptive as possible
Upload an image, screenshot or quote of your request

Browse Files

Cancelof
URL of request
Enter the URL of the website listing your request
Justification for request*
Be as descriptive as possible
Shipping Address Details
Delivery Date Requested if Approved*

MonthDayYear
Date
Where should the request be delivered to if approved?*

Street Address

Street Address Line 2

CityState

Zip Code
Northeast Texas Regional Advisory Council
2675 41st St SE, Suite 102, Paris, Texas 75462-8209
O-903.487.4344 F-903.993.4336 C903.640.3834
By signing, I hereby attest that I am authorized to make this request on behalf of my Agency/Facility*

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Needs Assessment Purchase Request