Braille and Access Technology for Students Initiative Vendor Information Form

Important Notice:

Please do not complete until you have all of the information to complete this form. The National Federation of the Blind of West Virginia is not responsible to obtain this information for you.

All required fields are marked with a *.

Student’s First Name *

Student’s Last Name *

Student’s Phone Number *

Student’s Email

Parent or Guardian’s First Name *

Parent or Guardian's Last Name *

Parent or Guardian's Phone Number *

Parent or Guardian's Email

Street Address *

Address Line 2

City *

State *

Zip Code *

First Device/software name

First Device/software Item Number

First Device/Software Price (without tax) $

First Device/Software Shipping/Handling Cost $

Vendor

Street Address

Address Line 2

City

State

Zip Code

Telephone Number

Email

Second Device/software name

Second Device/software Item Number

Second Device/software Price (without tax) $

Second Device/software Shipping/Handling Cost $

Vendor

Street Address

Address Line 2

City

State

Zip Code

Telephone Number

Email

Third Device/software name

Third Device/software Item Number

Third Device/software Price (without tax) $

Third Device/software Shipping/Handling Cost $

Vendor

Street Address

Address Line 2

City

State

Zip Code

Telephone Number

Email

Submitter's First Name *

Submitter's Last Name *

Submitter's Phone Number *

Search form

Important Notice: