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
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 except as shown on the accompanying Supplier Price Justification Conflict Information Form (SPJCI).

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:
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:
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