This form contains 19 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Approval
Director's Approval	Text	Please provide the name of the Divisional or Program Director approving this order form.
Approval Date	Date	Please enter the date of approval for this order form.
First Cost Center
field_1	Text
field_3	Text
Program Address
Program Name	Text	Enter the full official name of the program.
Program Information
Program Name	Text	Enter the full name of the program.
Program Address	Text	Enter the full street address including city and zip code for the program.
Program Contact	Text	Enter the name of the primary contact person for the program.
Phone Number Part 1	Text	Enter the first part of the program's phone number.
Phone Number Part 2	Text	Enter the middle part of the program's phone number.
Phone Number Part 3	Text	Enter the last part of the program's phone number.
Program Name
Program Name	Text	Enter the full name of the program or department with which the staff member is associated.
Second Cost Center
Second Cost Center Number	Text	Enter the number for the second cost center.
Second Cost Center Allocation Percentage	Number	Enter the percentage of allocation for the second cost center.
Staff Details
Staff Name, Degree/Licensure	Text	Enter the staff member's full name, followed by their highest earned degree, and any licenses or certifications if applicable.
Board/Job Title	Text	Enter the staff member's board-approved title (if licensed, certified, or registered) or their general job title. Fill only if 'Staff Name, Degree/Licensure' contains information that the staff is Licensed, Certified or Registered. Depends on: Staff Name, Degree/Licensure
Administrative Job Title	Text	Enter the staff member's administrative job title. Fill only if 'Board/Job Title' is filled with a Board Approved Title. Depends on: Board/Job Title
Third Cost Center
field_2	Text
Third Cost Center Allocation Percentage	Number	Please enter the allocation percentage for the third cost center.

Staff Information and Cost Center Allocation Form Instructions