PURCHASE REQUEST
PURCHASING USE ONLY
MARK THIS BOX TO HAVE A PURCHASE ORDER ISSUED
ORDER HAS BEEN PLACED WITH VENDOR
PAYMENT REQUEST
3.)PAGE __ OF __
MARK THIS BOX TO HAVE PAYMENT ISSUED
CAMPUS +4 ZIP
VENDOR EMAIL
QUANTITY PRICE
TOTAL
DATE PHONE EXT
12.)FUND / INDEX 13.)ACCOUNT
DATE
DATE
DATE
REV 04/19/16
CAMPUS +4 ZIP
7.)UNIVERSITY BUSINESS PURPOSE (REQUIRED)
PROVOST / VP FINANCE (SIGNATURE)
5.)SPECIAL INSTRUCTIONS
8.)INITIATOR (PRINT)
9.)DEPT CHAIR (PRINT) - UP TO $10,000.00
1.)VENDOR NAME
TELEPHONE
VENDOR FAX
REQUIRED DELIVERY DATE
DEPARTMENT
BLDG / ROOM
FEDERAL ID # OR SOCIAL SECURITY #
2.)ORDER DELIVERY INFORMATION
STREET ADDRESS / PO BOX
ATTN TO
TOTAL AMT
FORWARD ORIGINAL REQUISITION WITH ORIGINAL DOCUMENTATION ATTACHED TO THE PURCHASING DEPT., River Campus M2518 (+7022)
10.)DEAN / VP (PRINT) - UP TO $200,000.00
VENDOR ID #
CITY, STATE, ZIP CODE
DEPT CHAIR (SIGNATURE)
DEAN / VP (SIGNATURE)
LINE ITEM
PURCHASE / PAYMENT FORM
- A COMMITMENT MAY NOT BE MADE TO A VENDOR WITHOUT PRIOR
AUTHORIZATION FROM PURCHASING.
6.)DESCRIPTION OF ITEM (PROVIDE MFG. # , TYPE, MODEL, SPECIFICATIONS, ETC.)
4.)PURCHASE ORDER #
EXTENSION
ATTACHED [ ] INVOICE / RECEIPT [ ] QUOTE [ ] ENCLOSURE(S)
AMOUNT
11.)PROVOST / VP FINANCE (PRINT) - UP TO $500,000.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00