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Please review the following before submitting purchase request:

  • The item(s) requested for purchase must be in the approved Community Support Plan.
  • Purchase requests must be submitted 30 days prior to your service authorization end date.
  • Purchases will only be made from websites with secure payment options.
  • Purchases will not be processed from big-box retail stores such as Walmart, Target, Sam’s Club, or from ebay and companies outside of the United States.
For orders of more than 5 items, please use a separate form.
Item Number Item Name/Description Quantity Cost per Item Total Cost(Shipping/Taxes Included)
Total Purchase
$

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