Purchase
Change
Request
Fairmont State University
Procurement Office
1201 Locust Avenue
Fairmont, WV 26554-2470
Order #
FY Buyer Date Account # P.O. Date Contract #
Document:
□ Requisition (Cancellation Only)
□ Regular Purchase Order
□ Contract Purchase Order
□ Open End Contract Purchase Order
□ Agreement
Purpose of Change (Check boxes applicable):
□ Cancellation
□ Increase/Decrease
□ Unused Balance
□ Freight
□ Renewal
□ Extension Error
□ Error in Total Amount
□ Change of Account
Change or Vendor Name/Address
□ Other
Vendor Name, Address, Phone #, etc. Spending Unit Name & Address:
Fairmont State University
Procurement Office
1201 Locust Avenue
Fairmont WV 26554-2470
Item# Quantity Description of Change Unit Price Extended Price
Change Order # _______
Reason for Change Previous Total
Increase
Decrease
New Total
$___________
$___________
$___________
$___________
Approved: ___________________________________________
Authorized Procurement
Signature Date
__________________________________ ___________________________________________
Department Approval Attorney General (if required) Date
BOT/BOD79
click to sign
signature
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click to sign
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