Purchase Request Number:

^{DATE OF ORDER:} 

^{VENDOR NAME}

^{CONFIRMING TO:} 

^{P.O. NUMBER}

^ADDRESS

^{CITY/STATE/ZIP}

$van[20]

^{TELEPHONE NO.}

^{VENDOR NUMBER:}

Email

^{PAYMENT TERMS:}

^{SHIP VIA:}

^TAXABLE:

YES    NO   

^{DATE REQUIRED:}                                                                                           

^INCOTERMS:

^{DATE PROMISED:}

REQUESTOR COMPLETE THIS SECTION ONLY

ACCT. NO:

ITEM NO:

QUANTITY

UNIT PRICE

TOTAL

 $                -  

 $                     -  

 $                     -  

 $                     -  

 $                     -  

 $                     -  

 Total

 $                     -  

^{DELIVER TO THE FOLLOWING PERSON:}             

^{EXTENSION NO:}

 $van[22]

^REQUESTOR:            

^{EXTENSION NO:}

^{DATE of Request:}

^{DATE REQUIRED:}

Email:

^{APPROVAL DATE:} 

^{Approval Status:}

Department  Manager

 Signature / Electronic Signature

YES    NO   

^{APPROVAL DATE:} 

^{Approval Status:}

Final Approval

 Signature / Electronic Signature

YES    NO   

ATTACH SUPPORTING DOCUMENTATION