Please provide us with the following information:

* Required field

Name *

Member Number

Phone Number *

Email *

Club Name or Number (If a district officer, please provide your district number) *

What is the reason for this request and how will it be used? (Also indicate whether you are requesting a one-time use or an ongoing use of the materials, and in what capacity.) *

Please provide a description of the item or material to be used or created. When applicable, please also include the vendor name, vendor contact information, item number and cost. If you're requesting the use of an educational manual (in whole or in part) or other educational product, please include a citation of the source for requested use. *

Please upload a sample image of the item to be used or created.