Western Connecticut State University Purchasing Requisition
Document Text __________________________________________________ Contract Award Number ______________________________
__________________________________________________ Does Price Include Delivery? Yes [ ] No [ ]
Vendor Name: ____________________________ Competitive Pricing Information (if applicable) -
Address: ____________________________
____________________________ Vendor Name: ______________________ Vendor Name: ______________________
FEIN Number ____________________________ Address: ______________________ Address: ______________________
Contact: ____________________________ ______________________ ______________________
Phone #: ____________________________ Contact: ______________________ Contact: ______________________
Fax #: ____________________________ Price: $_____________________ Price: $_____________________
F
OR PURCHASING DEPT USE ONLY:
A
ssigned to ______________ FOB Code ______________ Terms _____________ Delivery Date ______________ PO # ______________
Approved by (Budget Authority) Date
Deliver to – (Dept Name/Building/Room Number/End User)
Date of Request
Department Charged Requested by Telephone # Date Required
Item
No.
Description Unit
Banner
Index
Unit Price Extension
TOTAL
$______
Requisition total dollar value
Requisition Number
Internal use ONLY – NOT a Purchase Order.
Products or services ordered and shipped
without valid purchase orders
are not considered contractual obligations of WCSU and if delivered
shall be refused and returned to the vendor at no cost to WCSU.
Quantity
Account Distribution: Banner Index Account Subcode Percent Amount
______________ ______________ _______ ________
______________ ______________ _______ ________
______________ ______________ _______ ________
______________ ______________ _______ ________
