Fill - Free fillable Purchase Check Request Form Purchase-Payment Request Form.xls PDF form

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

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

HOWTOCOMPLETEAPURCHASE/PAYMENTREQUESTFORM

Firstdetermineifyouneedapurchaserequestorapaymentrequest.IfyouwantanofficialUniversitypurchase

ordertobesenttoavendortoeitherplaceorconfirmanorderyouwillcheckthePURCHASEREQUESTboxatthetop

leftoftheform.Ind

icateifyouhavealreadyplacedtheorderwiththevendorbycheckingtheboxORDERHASBEEN

PLACEDWITHVENDOR.

IfyouhavereceivedgoodsorservicesandwanttopayforthemyouwillcheckthePAYMENTREQUESTbox.

Checkmarktheboxesindicatingwhetherthereisanattachmentwithyourrequisitionform.Originalreceiptsare

requiredforreimbursementsandaninvoiceisrequiredforvendorpaymentswiththeexceptionstipends/

honorariumsforguestspeakers.

Box1Providethefullnameofthecompanyorindividualprovidingthegoodsorserviceaswellasthecomplet

e

address.Atelephonenumberaswellasanemailaddresswouldbebeneficial.PleaseprovidetheFederalIDNumber

orSocialSecurityNumberforanycompanyorindividualperformingservices.

Box2Indicatewherethegoodsorservicesaretobedeliveredorperformedoncampus.

Box3Indi

catenumberofpagesif,yourPurchase/PaymentRequestFormhasmorethanonepage.

Box4IndicatethepurchaseordernumberifyouhaveobtainedonefromThePurchasingOfficeinadvance.

Box5Noteanyspecialhandlinginstructions.(e.g.Attachthecontracttopurchaseorder,faxorem

ailpurchase

ordertovendor)Ifthecheckistobesenttoanoncampusaddress,pleasenotethatinthissectionandattachan

addressedcampusenvelope.

Box6Indicatewhatyouarepurchasingorpayingfor.Ifyouareusingmorethanonepageforyourite

ms,please

numbertheitemsandmakesurethetotalonthelastpageiscorrect.Indicateaquantityandaunitpriceaswellasa

linetotal.Makesureyourdescriptionisdetailedandaccurate.Themoreinformationyouprovidethebetter.

Box7IndicatetheUniversitybusinesspurposeofth

eexpense.Thisisarequiredfield.Ifthisfieldisleftblankoris

uncleartherequisitionwillbereturnedtoyouforfurtherexplanation.

Boxes8–11Theseboxesareforthesignaturesrequiredtoprocesstherequest.Allnamesmustbeprintedand

signed.Eachboxindicatesthedollarthr

esholdatwhicheachsignatureisrequired.RefertotheUniversity’s“Policy

onAuthoritytoFormulateandSignContracts”.Proofofdelegatedsigningauthoritymayberequired.Providea

campus+4zipandacampusphonenumberfortheinitiatoroftherequisition.

Box12Indicatewhatfund/indexnumber/syouwishtheexpensetobepaidfrom.Thefund/indexmustbeone

thatthesignershaveauthoritytoapprove.Iftheexpenseisbeingsharedwithmultipledepartmentalfunds/indexes

bothsigningauthoritiesmustapprove.Anoriginalsignedmemofromthesupportingfund/indexauthorizedsigner

withadetail

eddescriptionmaybeattached.

Box13Indicatetheaccountnumbertheexpenseshouldbepaidfrom.

Whentheformiscompletedandsigned,mailordelivertheoriginalformtothePurchasingOfficewithalloriginal

documentationattached.Securelyattachalldocum

entsandenvelopestotherequisitiontohelpensuretheydonot

becomeseparated.Ifyouwishacopyoftherequisitionwiththeassignedpurchaseordernumbertobereturnedto

you,attachacopyoftherequisitiontotheoriginal.PurchasingislocatedinRiver CampusroomM2518.Campus

zipcodeis+7022.Ifyouhaveanyquestions,pleasecontactthePurchasingOfficeatx2641.

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