Web Requisition (312)

This is intended for Purchasing Internal Use Only and is not intended for internal fund transfers.
Web Requisitions Instructions

* Required fields in red

SHIP TO DEPT :
Address:
City:
State:
Zip
Room #:
Box #:
Bldg#:
Phone:
Fax:
Attn:
Suggested Supplier:
SUPPLIER CODE:
Order to Address:
City:
State:
Zip:
Phone:
Fax:
Attn:
	Yes		No	Patient Care Item
Value Analysis Signature
	Yes		No	Supplier Price Justification Form attached(orders > $25,000 or single source)
	Yes		No	Price verified with (name):

	Yes		No	Quotes / Contracts attached - # of quotes

Blanket Order?				Start Date and End Date: (format: m/d/yyyy - m/d/yyyy) - required if Blanket Order is checked
	Yes		No
Renewal ?
	Yes		No	------------------------------> Replaces PO Number
Desired Delivery Date:					m/d/yyyy
Each signer certifies, to the best of his or her knowledge, that this purchase is fair and reasonable and in the best interest of the university and that
no employee of the University or its affiliates who was involved in the purchasing decision has a conflict of interest per the University's conflict of interest policies, or
an employee of the University or its affiliates has a conflict of interest and the conflict information on the accompanying supplier price justification and conflict information (SPJCI) for is correct
Item# 1.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 2.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 3.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 4.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 5.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 6.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:
Item# 7.
PMM Item#
Supplier Catalog#
Qty / UM
Description
Unit Cost						Extended:

Additional Comments:
Requisition / Not to Exceed Total:				* Supplier Price Justification Form if over $25,000)
Yes		No		Capital Expenditure?
Click here for Approval (Signature) guidelines
Requestor Name:
Title / Date:
Department:
Intramural Address / Box#:
Phone / Email Address:

Dept / PI Approval Name:
Title / Date:
Dept / PI Approval Name:
Title / Date:
Division Approval Name:				** Required for Requisition Total over $50,000.00
Title / Date:
Senior Admin Approval Name:
Title / Date:

Charge Account (Name):
Division:
Account No.				10 digits no dashes or spaces
% Charged

Division
Account No.				10 digits no dashes or spaces
% Charged

Credit Account (Name):
Division / Account No. / % Credited
Division /Account No. / % Credited