Purchase Order - FY2020-24

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Purchase Order Request Form

Please use the form below to submit a District 1199C Training & Upgrading Fund Purchase Order Request. Submission of a Purchase Order Request Form does not guarantee payment.
Please consult with your supervisor to verify payment.

Submitter's (i.e. your) Name*

First Name

Last Name

Submitter's Email*

Date Requested*

This Purchase Order is for:*

Issuing a check Record of credit card usage Record of petty cash usage

Other:

Vendor's Name

Vendor's Address

Address Line 1

City

State

ZIP Code

Country

Payee Name IF DIFFERENT

If different from Vendor Name

Payee Address IF DIFFERENT

Address Line 1

City

State

ZIP Code

Country

Credit Card/Petty Cash Reimbursement to:

To your knowledge, is this a NEW vendor, or one the Training Fund has paid before?

New Vendor Existing Vendor I don't know

IF NEW VENDOR: Upload IRS Form W-9, if available

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If available

Funding Source or Grant Name*

If "Other," please specify

Product Description*

Product Price* $

Budget Line Item*

General Ledger Code to Charge*

If Other, Please Specify:

Include GL Code if Known

Upload Supporting Documentation (Invoice, Receipt, etc.)*

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Upload Additional Documentation (if necessary)

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Upload Additional Documentation (if necessary)

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Upload Additional Documentation (if necessary)

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Is this purchase being SHARED ACROSS MULTIPLE GRANTS/FUNDING STREAMS?

Yes No

A single purchase order may be used to split costs across up to four separate funding sources. However, four copies of the same PO must be saved to the Accounts Payable folder system!

Second Funding Source or Grant Name

GL Code in 2nd Source

Charge to 2nd Source $

Third Funding Source or Grant Name

GL Code in 3rd Source

Charge to 3rd Source $

Fourth Funding Source or Grant Name

GL Code in 4th Source

Charge to 4th Source $

Do you have another item for purchase FROM THE SAME VENDOR & FUNDING SOURCE?

Yes No

Product Description

Product Price $

Budget Line Item

General Ledger Code to Charge

If Other, Please Specify:

Include GL Code if Known

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Do you have another item for purchase FROM THE SAME VENDOR & FUNDING SOURCE?

Yes No

Product Description

Product Price $

Budget Line Item

General Ledger Code to Charge

If Other, Please Specify:

Include GL Code if Known

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Do you have another item for purchase FROM THE SAME VENDOR & FUNDING SOURCE?

Yes No

Product Description

Product Price $

Budget Line Item

General Ledger Code to Charge

If Other, Please Specify:

Include GL Code if Known

Upload Supporting Documentation (Invoice, Receipt, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Upload Additional Documentation (if necessary)

No File Chosen

File uploads may not work on some mobile devices.

Do you have another item for purchase?

Yes No

Please fill out the form again for additional purchase requests.

Purchase Order Total $

Request Date*

Requester Signature*

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Please identify the individual who must approve this PO request for further processing:*

As Executive Director, Teresa Collins is ONLY issuing "Final Approvals." If Teresa is your direct supervisor, please select your own or a peer's name for second-level review.

Second-Level Review (CHECK FOR ACCURACY!)

Is this Purchase Order Request approved?

Yes, I approve this request. No, this request is not approved

Program/Departmental Authorization Date

Notes on approval or disapproval

Signature: Program/Departmental Authorization

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Final Authorization

Authorized Signature

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Final Authorization Status

Notes on rejection

Final Authorization Date/Time