Indiana Billing, Shipment & Pickup Request Form

SHIP TO ADDRESS *

BILL TO ADDRESS *

BILL TO NAME *
BILL TO EMAIL *
example@example.com
BILL TO CONTACT NUMBER *
ALTERNATE CONTACT NAME *
Person who can be reached during the summer
ALTERNATE CONTACT EMAIL *
example@example.com
ALTERNATE CONTACT NUMBER *
LAST DAY OF SCHOOL *

- Month - Day Year
Date
FIRST DAY OF SCHOOL *

- Month - Day Year
Date
Required Authorization
AUTHORIZED PERSON NAME *
Person who can be reached during the summer
AUTHORIZED PERSON TITLE *
DATE *

- Month - Day Year
TRUCK SERVICE PICKUP REQUEST: Fill out only if you qualify for pickup service.

A minimum of 100 books is required for pickup
NUMBER OF TEXTBOOKS (PIECES) *
NUMBER OF LIBRARY BOOKS (PIECES) *
LOCATION OF BOOKS (door #, room name, area, etc.) *
CENTRALIZED PICKUP/DELIVERY LOCATION *

YES NO

CENTRALIZED PICKUP/DELIVERY ADDRESS *