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RocketSCAN for Free & Reduced Meal Applications

2010 - 2011 ONLY!

To start the 2010-11 application process, please fill out the form below and click submit (We recommend you print it prlor to submitting) Use the comment section to suggest Ideas or special requests; your Input is greatly appreciated. You will be contact within 24 hours to discuss if necessary.
NOTE:

Filling out this questionnaire does not constitute an order
Filling it out provides the information to create and send you a proposal for your 2010-11 applications needs
If you would like a copy of your 2009-10 online form submission or quantity of applications ordered please contact us

800-956-9000 ext. 390
rocketscan@image-1.com
We will accommodate your request within 24 hours

This form is for application orders only, you will receive notification when the Online Form is available for Application Development Information (i.e. meal prices, instructions, contacts, and phone numbers)

Fields in RED are required

District Information

School District
Contact Name
Phone Number
E-mail

Ship To Address Information
Physical address where printed applications are shipped

Attention
Address 1
Address 2
City
State
Zip Code

2010-11 first day of School

Please enter the first day
of school for your district.

Application Size
Please let us know the preferred dimensions you would like your form to be. We will do our best to accommodate the requested size content and state regulations permitting. All dimensions are in inches.

Application Dimensions

Application Amounts and Translations
Please provide us with the quantity of each application type you require for the 2010-11 school year Applications layout. There is a minimum order of 1,000 blank applications.

For English Applications Only

Quantity of blank ENGLISH applications
	Check only one
App with instructions on back (Most common)
App with Household letter on back (For district that preprint student information)

For Spanish Applications Only

Quantity of blank Spanish applications
	Check only one
App with instructions on back (Most common)
App with Household letter on back (For district that preprint student information)
District prefers Image One to provide translation (Price $1,000)

For Languages OTHER THAN English and Spanish Only

Quantity of blank OTHER LANGUAGE applications with instructions on back
Select language from dropdown list
District prefers Image One to provide translation (Cost will vary based on language selection)

For Two Sided (applications on both sides) Only

Quantity of blank applications with SECOND LANGUAGE on back
Side 1 of application
Side 2 of application
District prefers Image One to provide translation (Cost will vary based on language selection)

Other Comments

ONCE FORM HAS BEEN SUBMITTED YOU WILL RECEIVE EMAIL CONFIRMATION WITHIN 24 HOURS, IF YOU DO NOT PLEASE CONTACT US TO CONFIRM YOUR FORM HAS BEEN RECEIVED

Phone (800) 956-9000 ext. 390
Email: rocketscan@image-1.com

Filling out this questionnaire does not constitute a purchase agreement.
You will receive a proposal, it is imperative you review it and if it is acceptable, sign and fax it or a Purchase Order to Image One at your earliest convenience as the order in which we receive purchasing commitments will determine the priority Image One will use for application development.