Requisition Form

PAGE-1

Requisition #:

Business Unit:

see instructions

DELIVER TO:

DATE:

Requestor:

Extension:

DATE REQUIRED:

DEPT. NAME:

Requestor Email

REQUIRED INFO ABOVE !!!

COMMENTS:

see Contracts

Subtotal-Cont

see Public Works

Subtotal-Public Works

Quantity

Unit

Model or Catalog #

Description

Per Unit

Total

Category: see codes

Category:

add item 8

Suggested Vendor (Please Specify):

Sub-Total

Shipping/
Handling

SELECT THIS

PeopleSoft Chartfields (* = required)

Fund*	Dept ID*	Account*	Program	Project	Class	% or Qnty

State Contract/SPS / Reference #
___________

PROCUREMENT USE ONLY:

Requisition #

Mail check w/ P.O. and docs Mail Confirm
Check Request Debarment Review Required

Total before tax

F.O.B.

___________

Ordered by:

__________

Procurement Approval:

__________

Total after tax: $_______________________

Called in to: ____________________________________________

Delivery Date: __________________________________________

Fax to: ________________________________________________

Fax #: ________________________________________________

Date Faxed: ___________________________________________

P1B
PW
Contract

I HEREBY CERTIFY on my own personal knowledge that the articles or services requested hereon are necessary for use in my department
PRINTED NAME BELOW

Print name

Signature

_____________________________

Title:

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STATE OF CALIFORNIA INTRA OFFICE REQUISITION

STATE OF CALIFORNIA
INTRA OFFICE REQUISITION