Pacific University

Purchase Requisition

This is not a purchase order. Click on the item number below to jump to the Instructions web page which describes the item.

Department __________2___________ Date Ordered _____3_____ PO Number ______4______

Supplier (complete all lines of address):	Date Required ________6___________
Name ______________5_______________________	Method of Shipment _____7__________
Address ____________________________________	Campus Delivery Instructions:
City__________________ State _____ Zip ________	___________9____________________
Phone _________________ Fax ________________	________________________________
Pacific Univ. customer number: ________8_________	________________________________

Account Number	Qty	Unit Meas.	Item Number	Description	Unit Price	Estimated Cost
10	11		12	13	14	15
Shipping & Handling						16
Total

Requested by ________17_____________

Ext. ____18___

Approved by ______19______________

Copies Distribution: White to Purchasing; Yellow to Receiving Report; Pink is departmental copy.

Rev. 3/10/99