FORM A17-A (REV 07/29)



|FORM | |STATE OF WASHINGTON |DATE ORDERED |FIELD ORDER NUMBER |

|A17-A | |Field Order |7/29/2013 |XXXXXXX |

|(REV 7/13) | | | | |

|From: |AGENCY |

| |NO. |

|To: |Mail invoices to: |COPIES |AGENCY |LOC |MAIL |

| | |RQD. |NO | |STOP |

| | |

|AUTHORITY OR CONTRACT NO. |SHIP FROM |PRICE F.O.B. |PAYMENT TERMS |DELIVERY DATE |

Deliver the articles ordered below in accordance with the Standard Terms and Conditions (click here). Instructions to vendor: Show authorization number and field order number on all invoices, packages and shipping documents. Washington state sales tax applies to this order.

|ITEM NO. |COMMODITY CODE |

|PREPARED BY |TELEPHONE NUMBER |DATE |AGENCY APPROVAL |DATE |

|DOC DATE |PMT DUE DATE |CURRENT DOC NO. |REF. DOC NO. |VENDOR NUMBER |VENDOR MESSAGE |USE TAX |UBI NUMBER |

|REF |TRANS |M |FUND |

|DOC |CODE |O | |

|SUF | |D | |

Copy 1 for Vendor's Copy - Accounting Copy - Receiving Report

Copy 2 - Agency Copy

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