AGENCY PURCHASE REQUEST FORM

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					                                                                                           PURCHASE REQUEST NUMBER


                                                               STATE OF MAINE
                                            DEPARTMENT OF ________________________
                                                 AGENCY PURCHASE REQUEST
                                            FOR PURCHASES OVER $2,500 ATTACH SUPPORTING DOCUMENTATION
                                            DEMONSTRATING EMERGENCY OR ESSENTIAL NATURE OF PURCHASE

  DATE:           02/11/10
VENDOR CODE/REMIT ADDRESS:                                                    Contract #


                                                                                           Department of
               ORDER                                                            SHIP       Attn: Kirsten Howard
              ADDRESS                                                            TO        Winthrop St; Baker Bldg.
                                                                                           Hallowell, Me. 04347


              REMIT TO                                                          BILL
              ADDRESS                                                            TO




            Account Name:                                              Account Number #

                  USE BY:                                              NEEDED FOR:
          VEHICLE/BOAT #:

           APPROVED BY:

 LINE #       QUANTITY         UNIT                      DESCRIPTION OF ITEM(S) REQUESTED                              UNIT       AMOUNT
                                                                                                                      PRICE




                                                                                                                       Subtotal       $0.00
           exempt from Maine State sales tax.                                                              Shipping & Handling
                                                                                                                        TOTAL         $0.00