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-20-00)# *

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 Information

Same as above

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: Strengthening Capacity - North Carolinians will have libraries with essential resources and capable staff that enable them to provide exceptional library programs and services.

Goal 2: Expanding Access - North Carolinians will have expanded access to resources for learning and success in school, work, and life.

Goal 3: Community Engagement - North Carolinians will have libraries that are more effective because they cooperate, coordinate, collaborate, and communicate to help the community address its needs.

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.