Waiver Request Portal

Contact Customer Service Center at 855-842-7867 for orders or inquiry

Submit your waiver request by completing the form below. All fields marked with an asterisk (*) are required.

Agency Information

Agency Name *

Requestor Name *

Requestor Title *

Phone Number *

Email Address *

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

End User Name *

End User Title *

VIB Department

Waiver Reason *

Product Name *

Product Code *

Quantity *

UoM *

Product URL

Attachment

Additional Notes