Purchase Requisition - Wisconsin
|State of Wisconsin |REQUSITION NO. | |
|PURCHASE REQUISITION |THIS IS NOT AN ORDER Requisition Date: | |
|DOA-3066 (R08/2004) | | |
|ATTACH QUOTATIONS AND | | |
|RELATED INFORMATION | | |
| | | |
| | | |
| |enter type code: | | |Purchase Order No: |
| |1-Regular |4-Interagency |G-Grant (Pass-thru) | |
| |2-Change Previous |5-Blanket-Non Contract |L-Master Lease Program |Purchase Order Date: |
| |3-Cancel Previous |8-Blanket-Contract |P-Project (Construction) | |
|PLEASE PRINT OR TYPE | | |
|FUND |DEPT |APP |L1 |L2 |L3 |PROJ |CLASS |FY |CENT ACCTG |FOR AGENCY USE |Amount: |
| | | | | | | | | | | |$ |
| | | | | | | | | | | |$ |
| | | | | | | | | | | |$ |
|LINE |FUND |AGY |ORG |SUB |APPR |FUNCTION |ACTV |OBJ |SUB |RPTG CAT |PROJ # |FY |Amount |
| | | | |ORG | | | | |OBJ | | | | |
| | | | | | | | | | | | | |$ |
| | | | | | | | | | | | | |$ |
| | | | | | | | | | | | | |$ |
| | | | | | | | | | | | | |$ |
| | | | | | | | | | | | | |$ |
| | | | | | | | | | | | | |$ |
|Suggested Vendor: Name, Address, Zip Code +4 |Federal Employer Identification No./ Social Security |SHIP TO: Be sure Zip Code is correct for address. |
| |No.* | |
| | |Do not use P.O. Box address for shipments |
| | |
|F.O.B. |Terms |Delivery Date Desired |Reference |Agency Bid No. |SBOP Contract No. |
| | | | | | |
|Quantity |Unit |Description |Commodity |Unit |Total |
| | |Include Make, Color, Size, Model, Etc. |Code |Price |Costs |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
| | | | | |$ |
|Justification for expenditure if required. Attach additional sheet if necessary. |Total Estimated Cost |
| |$ |
| |Requisitioner Name |Telephone |Signature |Date |
|A | | | | |
|P |1st Level Approve Reject |Signature |Date |
|P | | | |
|R |2nd Level Approve Reject |Signature |Date |
|O | | | |
|V |Budget/Finance Approve Reject |Signature |Date |
|A | | | |
|L |Purchasing Approve Reject |Signature |Date |
|S | | | |
*If no FEIN is available, SS # must be provided for the State of Wisconsin to issue a check.
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