APH Building on Patterns REQUEST FORM E-mail order to:
Date:Student’s Name:
(exactly as listed on your “VIIB Database Report”)
Student’sGrade Level:
(2015-16school year) / Please verify this student meets the eligibility requirements for the Federal Quota Program and is therefore eligible to access the CIMC repository of APH braille paper. This information is reflected on your district’s “VIIBDatabase Report”.
Federal Quota Eligible?:Yes or No /
CIMC Use Only
order # 15-______input #lines on APH SS___
verify APH Elig: Yes No
tab #_ _
KLAS _ _ _ _ _
inv _ _ _
PO _ _ -15-_ _ _ _ _-_ _ _ _
Acct KLAS Number
APH web conf# ______
email AU order rec’d _____
email AU 1st SHP ______
email AU 2nd SHP______
email AU SHC ______
date AU confirmed receipt of complete order: ______
update spreadsheet: _____
Administrative Unit:
District:
Administrative Unit Contact Name:
Administrative Unit Contact Phone:
Administrative Unit Contact Email:
Name of TVI Requesting Order:
TVI Phone:
TVI Email:
Ship to:
Name:
Address line 1:
Address line 2:
City/State/Zip: / Additional Info (please indicate if teacher’s manual is needed):
PLEASE NOTE: There will no longer be “print kits” and “braille kits”. The new student kit will contain all the student materials in braille and the teacher’s manuals will be available separately. The teacher’s manuals have not changed at this time.
PRODUCT NAME / APH CAT NO. / TOTAL COST / CIMC use only
Date
pulled from CIMC inventory / CIMC use only
Date ordered from APH website / CIMC useonly
Date shipped out of CIMC or direct from APH
BOP UEB Kindergarten – Student Kit / 6-78550-00 / $321.00
BOP UEB Grade 1 Unit 1 – Student Kit / 6-78560-U1 / $190.00
BOP UEB Grade 1 Unit 2 – Student Kit / 6-78560-U2 / $153.00
BOP UEB Grade 1 Unit 3 – Student Kit / 6-78560-U3 / $153.00
BOP UEB Grade 1 Unit 4 – Student Kit / 6-78560-U4 / $153.00
BOP UEB Grade 1 Unit 5 – Student Kit / 6-78560-U5 / $153.00
BOP UEB Grade 1 Unit 6 – Student Kit / 6-78560-U6 / $153.00
BOP UEB Grade 1 Unit 7 – Student Kit / 6-78560-U7 / $153.00
BOP UEB Grade 1 Posttest Materials Teacher’s Manual Braille / 6-78562-00 / $30.00
BOP UEB Grade 1 Posttest Materials Teacher’s Manual Print / 8-78562-00 / $38.25
BOP UEB Grade 1 Posttest Materials Consumables Pack / 8-78565-00 / $40.00
BOP UEB Grade 2 Unit 1 – Student Kit / 6-78570-U1 / $271.00 /
BOP UEB Grade 2 Unit 2 – Student Kit / 6-78570-U2 / $225.00
BOP UEB Grade 2 Unit 3 – Student Kit / 6-78570-U3 / $219.00
BOP UEB Grade 2 Unit 4 – Student Kit / 6-78570-U4 / $225.00
BOP UEB Grade 2 Unit 5 – Student Kit / 6-78570-U5 / $257.00
BOP UEB Grade 2 Unit 6 – Student Kit / 6-78570-U6 / $221.00
BOP UEB Grade 2 Unit 7 – Student Kit / 6-78570-U7 / $224.00
BOP UEB Grade 2 Posttest Materials Teacher’s Manual Braille / 6-78572-00 / $28.00
BOP UEB Grade 2 Posttest Materials Teacher’s Manual Print / 8-78572-00 / $21.00
BOP UEB Grade 2 Posttest Materials Consumables Pack / 8-78575-00 / $28.00
TOTAL please: / $
Colorado Instructional Materials Center (CIMC): 1015 East High Street, Colorado Springs, CO 80903 Fax: 719-578-2207 Phone: 719-578-2196
…Learning, Thriving, Leading
33 N. Institute Street, Colorado Springs, CO 80903 719-578-2100 719-578-2239 fax
Revised 5/5/15