STAR Service Request Form

( * ) Required field

Contact Information

* Name:
Title:
* Organization/Agency:
* Phone Number:
* Email Address:
* Mailing Address:

Purchasing Information

Are you authorized to make purchases for your organization?
Yes No
If not, who is the point of contact for procurements?
Name:
Phone Number:
Email Address:
Mailing Address:

Package Selection and Scheduling

Requested Training Package: (Indicate the number of packages requested. Additional packages are not guaranteed.)
STAR National Training and Technical Assistance Package STAR Trainer Certification Package Partner State Expansion Package STAR Coaching PackageHow Many?
Have you reviewed the additional costs associated with the training packages? This information is available at www.startoolkit.org/addexpense.html.
Yes No
Do you agree to support the additional costs associated with the training packages?
Yes No
What month would you like to begin your STAR Training:
Month: Year:

Readiness

Have you thoroughly reviewed the “Ready for STAR?” section of the web site?
Yes No
If so, what questions do you have related to state and/or local program readiness?

Follow-up

Who would be the point of contact for future inquiries (e.g., to gather additional information or to schedule training)?

How did you learn about STAR?

Please note any details that may be helpful in the site selection process.

* (initial in the box) I understand that by submitting this Service Request Form I am committing to the purchase of the STAR training package selected above.