PURCHASING
DEPARTMENT
Box K-147
Phone: 309-341-7253
Fax: 309-341-7076
9/19
REQUESTOR’S NAME _____________________________________________ ID# _____________________________
DEPT ___________________________________________________________ CAMPUS BOX ____________________
PHONE _________________________________________ FAX ____________________________________________
PO# __________________________
(TO BE ASSIGNED BY PURCHASING DEPT.)
REQUEST FOR PURCHASE ORDER
SUGGESTED VENDOR VENDOR EMAIL DATE
ADDRESS CONTACT NAME
CITY STATE ZIP PHONE FAX
TERMS DATE REQUIRED SHIP VIA
QUANTITY DESCRIPTION STOCK NUMBER UNIT PRICE TOTAL
COMMENTS
CONFIRMATION OF ORDER
EMAIL CONFIRMATION TO VENDOR
FAX CONFIRMATION
EMAIL P.O. TO REQUESTOR
SHIPPING & HANDLING
TOTAL
IF ACTUAL PRICE IS NOT AVAILABLE, PLEASE ESTIMATE.
ACCOUNT TO BE CHARGED __ __ – __ __ __ __ – __ __ __ __ – __ __ __ __ __
MY SIGNATURE CONFIRMS I HAVE BUDGET FUNDS AVAILABLE (INCLUDING ENCUMBRANCES) TO COVER THIS PURCHASE.
APPROVED BY (PRINT) APPROVED BY (IF OVER $5,000, VP SIGNATURE REQUIRED)
APPROVER SIGNATURE
SUBTOTAL
0.00
0.00
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