LSTA Equipment Approval Request Form

Submit this form to request approval prior to purchasing any item with a per item cost of $5,000 or more.

Note: Upon reimbursement, approved equipment will be added to the State Library's Annual LSTA Equipment Tracking Survey for the remainder of its useful life. IMLS requires disposal be cleared with the State Library if fair market value at the time of surplus/disposal exceeds $5,000.

Library Information

Institution/Library *

State Project Code (Example: NC-22-00)# *

Grant Category *

Library Director, Name
(First Last, e.g., Jane Doe) *

Library Director, Phone number
(xxx-xxx-xxxx) *

Library Director, E-mail Address *

Project Manager, Name
(First Last, e.g., Jane Doe)

Project Manager, Phone number
(xxx-xxx-xxxx)

Project Manager, E-mail Address
Copy of form will be sent to this address *

Equipment Information

Select the State Library Five Year Plan Goal that this project supports. *

Goal 1: Community Engagement-North Carolina libraries will provide inclusive, user-focused services that enable community-wide growth and transformation.

Goal 2: Equitable Access-North Carolinians will have equitable access to information and technology needed to learn, live, govern, and work.

Goal 3: Responsive Organizations-North Carolina libraries will be places that all people find welcoming and accessible through sustainable organizational practices focused on inclusion, development, and community responsiveness.

Item #1 - Cost per item *

Item #1 - Quantity to be purchased *

Item #1 - Briefly describe the item (brand, type) and why this item is important to the project. *

0/350 characters

Item #2 - Cost per item

Item #2 - Quantity to be purchased

Item #2 - Briefly describe the item (brand, type) and why this item is important to the project.

0/350 characters

Item #3 - Cost per item

Item #3 - Quantity to be purchased

Item #3 - Briefly describe the item (brand, type) and why this item is important to the project.

0/350 characters

If there are more than 3 item types that need approval, or if you have items that support a different Five Year Plan Goal, please complete and submit an additional form.