SJTSA
Serving Atlantic, Cape May, Cumberland,
and Salem Counties

            Established 1998                                      

            To order print this form and fax to Teresa at 856-794-2549.

SOUTH JERSEY TRAFFIC SAFETY ALLIANCE

       ITEM REQUEST FORM

To justify to the state how the Alliance uses the promotional/safety items it purchases, members are now required to complete this form and submit it to Teresa for review and approval. Please use one form per event/program and be specific in the description area, including who your target audience is.

Requesters Name:

Organization Name and Address:

Telephone Number:

Item(s) requested:

Quantity requested:

Date required:

Description of Program/Activity, including audience, location, date and time:
Is this a new or existing program.  Any follow up programs or evaluations to be done?

1173 E. Landis Avenue, Vineland, NJ 08360   Tel: 856-794-1941  Fax: 856-794-2549