Requisition for Equipment, U.S.

Department of Labor
Supplies, or Services Office of the Assistant Secretary for
Administration and Management
1. Requisition No. 2. Bureau 3. Page No. of pages 4. Date

5. Allotment and Appropriation 6. Deliver to: (Specify, if inside delivery is required)

Name
Line 1
7. For Information Call (Name, Extension) City
Line 2 State Zip

8. Signature and Title of Approving Officer Inside Delivery Required Yes No

9. Item No. 10. Stock No. 11. Description of Articles of Services 12. 13. Unit 14. Unit of 15. Amount
Quantity Price Issue

VENDOR
Company:
Contact:
Address:

Phone #:
Fax #:
To be completed by supply activity
16. Shipped Via Freight 17. Filled by 18. Packed by 19. Checked by
Parcel Post
Mail Date Date Date
20. Date of Shipment 21 Bill of Landing No. 22. Estimated Cost of Shipment

To be completed by receiving activity (Optional)

23. Signature Title Date

Reset Print

DL Form 1-1
Rev. June 1983