Check Out - Bancroft BHS Portal

Bancroft Order Form

"*" indicates required fields

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Order Total Numeric

This to hold only numeric to verify

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Program Director Name*

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Approval Email - Program Director*

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Senior Director Name*

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Approval Email 2- Senior Director*

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Butler Rep Email

Date: 05/29/2026

Requester's Name:*

Requester's Email*

Requester's Phone:*

GL #:*

Location:*

Location Address*

Street Address Address Line 2 City State ZIP Code

Delivery Address*

Same as Location Address

Will you be the contact person for the delivery of the order?*

Yes, I will be the contact.

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

Is there power/electricity in the facility?*

Yes

If we are running ahead of schedule, may we contact you for an earlier arrival?*

Yes

Are there any other special delivery or parking instructions?

Description of Item(s)

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Ordered Items

SKU

Item

QTY

Price

Total

This information gets added to form at check out

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Sub Total

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Delivery & Setup Fee

There is a minimum delivery fee of $200.

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Estimated Tax

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Order Total

Butler 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.

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Procurement Supervisor