FOR PURCHASING OFFICE USE ONLY
Purchase Order #:
Bid #:
State Contract #:
GL Acct #:
Purchase Codes:
Date Request Received:
Date Order Placed:

Purchase Request Form

Department or Alternate Funding Source (ie., name of Grant)

PLEASE NOTE: This form is for Business Card Orders Only Please select quantity desired and complete the information in the shaded area.

Quantity	Description	Unit Price	Total
Select One	☐ 250 Business Cards ☐ 500 Business Cards	$79.00 $89.00
Name
Title
Select One	☐ 1410 Highway 304 East, Pocahontas, AR 72455 ☐ 1 Black River Drive, Paragould, AR 72450 ☐ _______________________________ (i.e. Fire Science Address)
Email
Phone & Fax	Ph Fx
*(Include Shipping & Handling If Known)	S & H*
*(Include Sales Tax Of 8.75%)	Tax
GRAND TOTAL

VENDOR:	ASU Printing Department
Contact:	Dave Maloch
Address 1:	Box 1930
City/State/Zip:	State University, AR 72467
Telephone:

GENERAL LEDGER ACCOUNTS To be completed by Departmental Supervisor
6203-Copier Expense
6205-Conference/Educ/Training
6206-Instructional Supplies
6207-Office Supplies
6208-Shop/Industrial Supplies
6209-Maintenance/Custodial
6210-Subscription
6211-Memberships
6213-Promotional Items
6300-Capitalized Equipment
6302-Library (Books/Audiovisuals)
List other accounts below as needed
Signature of Requester	Date
Signature of Departmental Supervisor/Budgetary Approval	Date
Signature of VP of Administration	Date

*S & H and Tax will ultimately be added to your order and will impact your budget.
.

February 25, 2013 / AF