Purchase Order Request Form ver 03.10 [SearchToll]

PURCHASE ORDER REQUEST FORM

Instructions:

For institute or trust accounts, substitute "Program" or "Principle Investigator" with "Account" or "Account Holder" wherever applicable. Submit TWO COPIES of the completed form as follows:1. Signed Copy: Send a signed copy of the Purchase Order Request Form to the Foundation. (emailed PDF or fax is preferred)2. Excel File: Save a copy of the completed Request and email the Excel file to the Foundation for PO processing.Submit Forms to: Sponsored Programs & Institute Accounts: yashmeen.imroz@https://www.sodocs.net/doc/964605914.html, ; Trust Accounts: jayme.troung@https://www.sodocs.net/doc/964605914.html, 1. Program Name Principle Investigator College/Department Delivery Address Telephone Contact Person Address Telephone

Fax Email

Website

Describe item or service. Include manafacturer, model #, size, color, or other pertinent specifications and attach vendor quote for each item. For services, attach a complete Qty Unit Price Total 1.

0.002.

0.003.

0.004.

0.005.

0.00Purchase Order Total (before tax & shipping)

0.00

5. Purchase ≥ $5,000Does purchase order total meet or exceed $5,000?

*If no, attach single written price quote from suggested vendor.6. Sole Source Authorized Signer Date

Foundation Approval Date

(REV 02/10)Provide reason why other vendors cannot be considered for this procurement:

If requested item is not specifically identified in approved budget, explain how this purchase benefits the program:Program Chartfield

4. Program Benefit Account Fund Dept ID Program Class Project

3. Requested Item(s)

**If yes, attach a minimum of three written price quotes or complete Sole Source Justification at No. 6 below. NOTE : If

the estimated price is equal or greater than $50,000, do not obtain price quotes. The Foundation will handle the

solicitation process pursuant to open competition requirements unless No. 6 below is completed.

2. Requested Vendor

Print Name Print Name Yes**No*