DocuSign Envelope ID: 4E5FC3EA-5675-4DB5-B44B-1FF48D3933F4
campuslabs Data Driven Innovation Campus Labs Billing Information Form Revelant Information for Procurement/Finance
Primary Contact Information
Institution Name: Kentucky State University
Primary Contact: Deneia Thomas. PhD Title: Asst. VP, Academic Affairs
Mailing Address: 400 E. Main Street Frankfort, KY 40601
City, ST ZIP:
Phone: 502-597-5531 Fax: 502-597-6409
Email: deneia.thomas@kysu.edu Send invoices to my attention: Yes □ No □
Billing Information (if different than above)
Billing Contact: Title: Mailing Address: City, ST ZIP: DENEIA M. Thomas Assoc Up Academic Assort. D Evo Kentucky State University HOE MAIN STREET, 202 Hamey Hall Frankfort, Key 40601
Phone: 559 75531 Fax: 502-597-6409 Email: deveria.thomas@kepw.edu
Will Campus Labs be issued a PO for this requisition? Yes ☐ No ☐
Is a Campus Labs invoice required for PO generation? Yes ☐ No ☐
PO number is provided:
T: 716.270.0000 F: 716.652.2689
Campus Relations Contact: Andrew Lyle
www.campuslabs.com
210 Ellicott Street, Suite 200 Buffalo, NY 14203