Safety Equipment Application Safety Equipment Grant Application Step 1 of 2 50% Member InformationMember Name* First Last Date* Date Format: MM slash DD slash YYYY Member's Contact Person for Grant* First Last Phone*Email* Items for ReimbursementHow many items are you claiming?*Please enter a number from 1 to 10.Item 1 Name or Description*Quantity*Date Purchased* Date Format: MM slash DD slash YYYY Department Utilizing Item*PO or Check #*Cost*Invoice(s) or receipt(s)* Drop files here or Accepted file types: jpg, gif, png, pdf. Item 2 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 3 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 4 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 5 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 6 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 7 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 8 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 9 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Item 10 Name or DescriptionQuantityDate Purchased Date Format: MM slash DD slash YYYY Department Utilizing ItemPO or Check #CostInvoice(s) or receipt(s) Drop files here or Accepted file types: jpg, gif, png, pdf. Total for ReimbursementIf this amount is not correct, double-check the Cost fields for each Item above.