VISA CREDIT CARD PURCHASE REQUEST
LINE ITEM PART NO. DESCRIPTION
REQUEST DATE: 11/10/200 9 UNIT/ ISSUE
REQUIRED DATE:
PRIORITY
QTY
UNIT PRICE
TOTAL
ea. ea. ea. ea. ea. ea. ea. ea.
(LAST ITEM MUST BE WRITTEN AFTER LAST ITEM) SUGGESTED SOURCE:
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
REMARKS: (Services require 65 digit OMA fund appropriation)
NOTE: ITEMS CANNOT BE BACKORDERED REQUESTOR SIGNATOR: ____________________________________________________________________________ GSA CUSTOMER CATALOG HAS BEEN CHECKED FOR MANDATORY NIB/NISH/UNICOR/ ITEMS: Yes No
TELE#
________________ (CARDHOLDER MUST INITIAL) DATE: 11/10/2009 CARDHOLDER SIGNATURE: ____________________________________________________________________________ (REQUIRED) DATE: 11/10/2009 IMO SIGNATURE: ____________________________________________________________________________ (FOR ADPE PURCHASES WHICH REQUIRE A CAPR) DATE: 11/10/2009 BUDGET OFFICER SIGNATURE: _________________________________________________________________________ (REQUIRED OR DATE OF MEMO OF CERTIFIED FUNDS) DATE: 11/10/2009 APPROVING OFFCIAL SIGNATURE: _______________________________________________________________________ (REQUIRED) SHIP TO: AFTER PURCHASES -- ATTACH RECIEPTS (receipt cannot state Misc.) FT LEE Form 443-1E Rev. Oct 98
FILE NAME:
PR&C