COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
PURCHASE OF GOODS/SERVICES REQUISITION FORM
Form is not complete unless accurate, all signatures obtained, and required documentation attached.
Requested by:
Work Unit:
Phone:
Dated Requested:
Date Needed:
Fax Number:
Requested Vendor:
Vendor FEIN:
Vendor Phone:
Vendor Address:
Item(s) or Service Requested (Please be specific):
Qty
Unit
Complete Description
Item #
Unit Price
Total
$
TOTAL:
$
Approvals:
Authorized Signature:
Date:
Authorized Signature:
Date:
OSA Delegate (if required):
Date:
Shipping Information:
Facility:
Address:
Bldg No.:
City, State, ZIP:
SHIP CODE:
Requestor Checklist (Form will not be accepted by Accounting/Purchasing and Contracts without being completed, all
signatures obtained, and required documentation attached.) PLEASE CHECK ALL THAT APPLIES:
Goods $10k - $150k:
_____
Services <$25k:
_____
Services >$25k <$150k:
_____
Vendor Quote w/in 30 days: ____
Scope of Work Attached: _____
Product Picture attached: ____
Sole Source: ____
Sole Source Justification: ____
Personal Services Cert: ____
Business Case: _____
Personal Services Waiver: _____
Cost Analysis: ____
Insurance Certificate: _____
Documented Quote Required: ___
>$150k RFP/IFB/AFB required: __
PLEASE NOTE PROCESSING TIMES AND PLAN ACCORDINGLY, allow additional time for procurements requiring BIDS:
Accounting: 5 BUSINESS days from receipt; Purchasing and Contracts: 5-7 BUSINESS days from receipt.
CORE Funding Codes:
LINE
FUND
DEPT
UNIT
APR UNIT
OBJT
ACT
LOC
PROG
AMOUNT
% STATE/
CODE
CODE
FED
________________________________
DMVA Accounting Approval
Date
PAC Revised: 09/25/2015
COLORADO DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
PURCHASE OF GOODS/SERVICES REQUISITION FORM
Form is not complete unless accurate, all signatures obtained, and required documentation attached.
Requested by:
Work Unit:
Phone:
Dated Requested:
Date Needed:
Fax Number:
Requested Vendor:
Vendor FEIN:
Vendor Phone:
Vendor Address:
Item(s) or Service Requested (Please be specific):
Qty
Unit
Complete Description
Item #
Unit Price
Total
$
TOTAL:
$
Approvals:
Authorized Signature:
Date:
Authorized Signature:
Date:
OSA Delegate (if required):
Date:
Shipping Information:
Facility:
Address:
Bldg No.:
City, State, ZIP:
SHIP CODE:
Requestor Checklist (Form will not be accepted by Accounting/Purchasing and Contracts without being completed, all
signatures obtained, and required documentation attached.) PLEASE CHECK ALL THAT APPLIES:
Goods $10k - $150k:
_____
Services <$25k:
_____
Services >$25k <$150k:
_____
Vendor Quote w/in 30 days: ____
Scope of Work Attached: _____
Product Picture attached: ____
Sole Source: ____
Sole Source Justification: ____
Personal Services Cert: ____
Business Case: _____
Personal Services Waiver: _____
Cost Analysis: ____
Insurance Certificate: _____
Documented Quote Required: ___
>$150k RFP/IFB/AFB required: __
PLEASE NOTE PROCESSING TIMES AND PLAN ACCORDINGLY, allow additional time for procurements requiring BIDS:
Accounting: 5 BUSINESS days from receipt; Purchasing and Contracts: 5-7 BUSINESS days from receipt.
CORE Funding Codes:
LINE
FUND
DEPT
UNIT
APR UNIT
OBJT
ACT
LOC
PROG
AMOUNT
% STATE/
CODE
CODE
FED
________________________________
DMVA Accounting Approval
Date
PAC Revised: 09/25/2015
