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For office use only Date received ______ Date sent____________

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For office use only Date received ______ Date sent____________ Powered By Docstoc
					For office use only
Date received ________
Date sent____________
                              Concordia Parish School Board
                              Special Populations Department
                                  Ink Cartridge Request

               Teacher Name ___________________________________________

               School __________________________________________________

     PLEASE CIRCLE THE CARTRIDGE NUMBER(S) YOU ARE REQUESTING.

                            BLACK CARTRIDGE COLOR CARTRIDGE
                                    HP45                        HP78
                                    HP56                        HP57
                                    HP96                        HP97
                                    HP88                  HP88 YELLOW
                                                           HP88 CYAN
                                                        HP88 MAGENTA
                                    HP74
                                    HP15
                                CANON 104
                                CANON X25


                     If your cartridge is not list please list the make of the printer

                         (such as HP Deskjet 6980, Canon Imageclass 4350, etc)

                                   and the cartridge numbers below

                         Printer ________________________________________

       Black Cartridge _________________ Color Cartridge _________________

 Teacher Signature _______________________________________Date _____________

                             This request may be faxed to 336-3486.

				
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