Bancroft Order Form "*" indicates required fields Order Total NumericThis to hold only numeric to verifyProgram Director Name*Approval Email - Program Director* Senior Director Name*Approval Email 2- Senior Director* Butler Rep Email Date: 10/28/2026Requester's Name:*Requester's Email* Requester's Phone:*GL #:*Location:*Location Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Address* Same as Location Address Delivery Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Will you be the contact person for the delivery of the order?* Yes, I will be the contact. No Name of Delivery Contact* First Last Delivery Contact Phone*Delivery Contact Email* How many floors are involved in the delivery?*Is there an elevator?* Yes No Is there power/electricity in the facility?* Yes No If we are running ahead of schedule, may we contact you for an earlier arrival?* Yes No Are there any other special delivery or parking instructions?Description of Item(s) Ordered ItemsSKUItemQTYPriceTotal Add RemoveThis information gets added to form at check outSub TotalDelivery & Setup FeeThere is a minimum delivery fee of $200.Estimated TaxOrder TotalButler Order Support Contacts Butler Human Services bancroftsales@butlerhumanservices.com (877) 852-0784 Butler Rep corporate@email.com 555-555-5555 Program Directors Email* Senior Directors/Senior Clinical Directors Email* This is required when order exceeds $2500.Procurement Supervisor Continue
