Fillable Printable Purchase Order Request Form Sample

Purchase Order Request Form Sample

Justification Needed? (Circle one) Yes No

Suggested Vendor:

Address:

Phone:

Date Wanted:

Fax: Contact:

Shipping Instructions:

Purchase Order Request Form

(Shaded areas for Purchasing use only)

Date: Purchase Order Number:

Requestor: Bldg: Room No: Phone Ext:

Principal Investigator: Budget Code: Dept:

Comm

Codes

Qty

Unit

Issue

ITEM NAME AND DESCRIPTION

(Include manufacturer, name, model or type number and any other

identifying information)

Catalog

Number

Unit Price

Total Cost

If modifying existing equipment, ADD VALUE to UCI Property Number:

F.O.B. Ship By: Terms: Delivery Location:

Spoke To: Tax Code: Delivery Date:

Vendor Ref # Buyer: Date:

Approved By: 9-

**Urgent**

Packing slip must be turned in

to Purchasing, RH 162, within

3 days of receipt of order.

CHECK BOX IF THIS IS A PRECURSOR CHEMICAL