Purchase Order Request Form

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Purchase Order Request Form
(Shaded areas for Purchasing use only)
09/17/2012
Date:
Purchase Order Number:
Requestor:
Bldg:
Room No:
Phone Ext:
Principal Investigator:
Budget Code:
Dept:
Approved By:
9-
9-
Justification Needed? (Circle one)
Yes
No
**Urgent**
Suggested Vendor:
Packing slip must be turned in
to Purchasing, RH 162, within
Address:
3 days of receipt of order.
Phone:
Fax:
Contact:
Date Wanted:
Shipping Instructions:
CHECK BOX IF THIS IS A PRECURSOR CHEMICAL
ITEM NAME AND DESCRIPTION
Comm
Unit
Catalog
Unit Price
Total Cost
.
Qty
Of
(Include manufacturer, name, model or type number and any other
Number
Codes
Issue
identifying information)
If modifying existing equipment, ADD VALUE to UCI Property Number:
F.O.B.
Ship By:
Terms:
Delivery Location:
Spoke To:
Tax Code:
Delivery Date:
Vendor Ref #
Buyer:
Date:
Purchase Order Request Form
(Shaded areas for Purchasing use only)
09/17/2012
Date:
Purchase Order Number:
Requestor:
Bldg:
Room No:
Phone Ext:
Principal Investigator:
Budget Code:
Dept:
Approved By:
9-
9-
Justification Needed? (Circle one)
Yes
No
**Urgent**
Suggested Vendor:
Packing slip must be turned in
to Purchasing, RH 162, within
Address:
3 days of receipt of order.
Phone:
Fax:
Contact:
Date Wanted:
Shipping Instructions:
CHECK BOX IF THIS IS A PRECURSOR CHEMICAL
ITEM NAME AND DESCRIPTION
Comm
Unit
Catalog
Unit Price
Total Cost
.
Qty
Of
(Include manufacturer, name, model or type number and any other
Number
Codes
Issue
identifying information)
If modifying existing equipment, ADD VALUE to UCI Property Number:
F.O.B.
Ship By:
Terms:
Delivery Location:
Spoke To:
Tax Code:
Delivery Date:
Vendor Ref #
Buyer:
Date:

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