Figure V.H.5 – Purchase Requisition Form
SAMPLE ORGANIZATION - PURCHASE REQUEST
VENDOR REQUISITION
DATE:
NAME:
(If
A New Vendor Complete All Blanks This Side) NEED
BY DATE:
ADDRESS: LATEST
DATE ACCEPTABLE:
CITY & STATE: PERSONAL OR BUSINESS
(circle one)
ZIP: SHIPPING
ADDRESS: (circle
one)
STATION OR RANCH
CONTACT: SPECIAL
INSTRUCTIONS:
PHONE:
FAX: SHIP
VIA: (circle one)
E-MAIL: FED
X UPS US MAIL TRUCK
TYPE OF SERVICE: P.I.
OR DEPT HEAD:
OR TYPE OF SUPPLIES: REQUESTED
BY:
OUR ACCT # WITH VENDOR: VENDORS
REFERENCE #:
VENDOR FEDERAL I.D. #: SPECIAL
DISCOUNT TERMS:
OR SOCIAL SECURITY #: PAYMENT
METHOD: (circle one) Open Charge Check AMEX VISA
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COST CENTER |
ACCT # |
DESCRIPTION |
QTY |
UNIT MEASURE |
PRICE EACH |
VENDOR DESCRIPTION OR PART NUMBER |
TOTAL PRICE |
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THIS ORDER WAS
PHONED (FAXED) IN ON:_______________
Approval Date