Colorado Instructional Materials Center APH Technology Order Form
Email form to:
Date: /CIMC Use Only
Date Received by CIMC:TVI Requesting: /
KLAS MatReq#:
TVI’s Email: /Serial #:
MAC Address:
TVI’s Phone: / CIMC Barcode: 140 ______Administrative Unit: /
Order Mailed:
/Order Picked Up:
School District (if different than AU): / School District: Please fill in any special requests or instructions in this box.Please include shipping address:Administrative Unit Contact (if different than TVI):
Student: / Federal Quota Eligible: YesNo
Grade Level:
Please select one of the following:
Book Port Plus ($329.00): Book Port DT ($399.00):
Refreshabraille 18 Revised ($1,695.00): Braille Plus 18 ($3,599.00):
Orion TI-84 Plus Talking
Graphing Calculator ($599.00): Orion TI-30XS MultiView
Talking Scientific Calculator ($399.00):
Date Device is Needed:
The CIMC manages the Federal Quota accounts for the Colorado Department of Education. TVI may access the CIMC repository of APH Instructional Products for their students if the student is eligible for the Federal Quota Program the day the order is placed. All APH technology devices are the property of the CDE/CIMC and must be returned in working order to the CIMC upon request, or when the student exits the District/BOCES or when not in use by the student. Please read attached terms and conditions prior to signing.
Printed name of Requester:______
Signature of Requester:______Date:______
Printed name of Director of Special Education,
Supervisor, or Designee:______
Signature of Director of Special Education,
Supervisor, or Designee:______Date:______
September 2015
Terms and Conditions
School District/BOCES staff understand and agree that the District/BOCES is responsible for the proper handling, storage, use, care, maintenance and return of the device(s), component(s) or accessory(ies) loaned to the District/BOCES. District/BOCES staff understand that the device(s), components(s) or accessory(ies) are for school use only and therefore will remain on school property at all times.
The District/BOCES shall pay all costs for insurance and the return of all device(s), component(s) or accessory(ies) to the Colorado Instructional Materials Center (CIMC) when the student exits the District/BOCES or upon written request from the CIMC.
In the event the device(s), component(s) or accessory(ies) are lost, the District/BOCES shall be liable for the current replacement value. The CIMC requests the District/BOCES shall immediately contact the CIMC at 1-719-578-2196.
In the event of a theft of the device(s), component(s) or accessory(ies), the District/BOCES shall not be responsible if the District/BOCES immediately reports the theft to the local law enforcement agency and provides a copy of that report to the CIMC.
In the event that the device(s), component(s) or accessory(ies) malfunction, the District/BOCES shall immediately notify the CIMC at 1-719-578-2196. The CIMC will not be able to provide a replacement device during the repair period.
The District/BOCES shall be responsible for any and all damages or decrease in value of the device(s), component(s) and accessory(ies) beyond normal wear and tear to be determined soley at the discretion of the CIMC.
The District/BOCES shall not transfer or give the device(s), component(s) and accessory(ies) to any third party including parents of students who use the device(s).