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Purchase Order Request Form

Req. No. ________________________

Purchase Order No. ________________________

Account No. ______________________

Account Name ____________________________

Professors Name ______________________

Signature __________________________________

Your Name ______________________ Your Email __________________________ Your Phone Number ______________
Date __________________
Special Instructions:
Item
No.

Description

In Stock

Quantity

Unit
(each, pkg, case)

Lead Time __________________

Shipping Preference

Ground

Per-Unit
Price

Line Item Total


Price

Total Price ____________

Express

Complete Name of Vendor: ________________________________ Name of Contact: ______________________


Address of Vendor:________________________________________ Contacts phone number: ________________
________________________________________ Contacts fax number: __________________
Please attach any web printout or email or faxed quotation received from vendor.

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