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priority level
1
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Campus: SLO: NCC:
Employee Making Request:
Phone Number:
Date:
Description of Requested Items/Repairs/Training:
Anticipated Safety Benefit:
Itemized Breakdown of Cost (attach bids or photocopy if from a catalog or website):
Unit Cost:
Sales Tax:
Shipping:
Installation Fee:
Total Cost:
Signature of Supervisor/Director: Date:
Approved as Submitted: Yes No
Copy of Supporting Documentation Received: Yes No
Reason for Denial:
Signature of Safety Coordinator: Date:
SECTION ONE: TO BE COMPLETED BY REQUESTOR/SITE ADMINISTRATOR
SECTION TWO: TO BE COMPLETED BY SAFETY COMMITTEE
FUNDING REQUEST
Approval of request for funds will be reviewed and approved on merit
by the Cuesta College Safety Committee
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signature
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