PURCHASE REQUEST FORM

PURCHASE REQUEST FORMATTACH ALL VENDOR QUOTES!The costs provided on this form can be estimated costs.Grant Type/Budget Yr.Point of ContactSHIP TO THE FOLLOWING ADDRESS:Budget Line Number(s)(Office Use Only)Team/Depart.Phone NumberNameAddressPhone NumberITEM INFORMATION (enter all requested information)Item # Category Type Quantity Manufacturer* Model #* Description/JustificationVENDOR INFORMATION (enter all requested information)State Contract**Sole Vendor**Item # Company Name Company Point of Contact Phone NumberCompany City, State, ZipTotal CostsItem #Company NameCompany Point of ContactPhone NumberCompany City, State, ZipTotal CostsItem #Company NameCompany Point of ContactPhone NumberCompany City, State, ZipTotal Costs*Unless documentation is provided that a particular manufacturer & model number number is needed, we reserve the right to purchase acceptable equivalents.**Supporting documentation must be provided (i.e. copy of state contract or web reference). Sole Vendor is defined as the only company that manufactures/sells a particular item. Supporting documentationmust be provided verifying the sole vendor status.

PURCHASE REQUEST CONTINUATION FORMATTACH ALL VENDOR QUOTES!Item #CategoryTypeQuantityManufacturer*Model #*Description/Justification*Unless documentation is provided that a particular manufacturer & model number number is needed, we reserve the right to purchase acceptable equivalents.