Skip to form

Inland Regional Center

info@inlandrc.org

1365 S. Waterman Ave., San Bernardino, CA, 92408, US

Master Trust of California

Online Purchase Request

Please fill out form completely.  If you need assistance with the form, please view the video tutorial on this site or contact Trina Boyce at 909-382-4833.

Please note, if some items requested are not available, the remainder of the items will still be ordered. You may resubmit for missing items on a new request form.

Personal Information

Request Date

Date Picker

Indicate the type of benefits beneficiary receives (check all that apply)

Purchase Information

Do you have other items to add to this request?

Do you have other items to add to this request?

Do you have other items to add to this request?

Do you have other items to add to this request?

Total Amount of Purchase

Shipping Information

Shipping Address

For Master Trust Use Only:

Trust #

Balance:

Approved by:

Purchase Made By:

Date Purchase Made:

Notes: