Requested By   First Name M. Last Name First Name / Last Name

Phone Number    -  -  (XXX)-XXX-XXXX

Email Address

Authorized By   First Name M. Last Name First Name / Last Name

School   Select a School Dr. Charles A. Bejarano Elementary School Las Lomas Elementary Miami Jr. High School Miami Jr/Sr High School

Department

* Date Requested

TO BE COMPLETED BY OFFICE SECRETARY

Purchase order #

________________________________________

Date Ordered

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Processed By   First Name M. Last Name

Vendor Name

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Purchase Order #

Item Number

Item Description ( Name, Color, Size, etc.)

Item Price

Quantity

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Priority of the item needed   Low Normal High

Vendor Name

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Item Number

Item Description ( Name, Color, Size, etc.)

Item Price

Quantity

Additional Notes

Priority of the item needed   Low Normal High

Vendor Name

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Item Number

Item Description ( Name, Color, Size, etc.)

Item Price

Quantity

Additional Notes

Priority of the item needed   Low Normal High

Vendor Name

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Item Number

Item Description ( Name, Color, Size, etc.)

Item Price

Quantity

Additional Notes

Priority of the item needed   Low Normal High

Vendor Name

Address   Address 1 Address 2 AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code

Item Number

Item Description ( Name, Color, Size, etc.)

Item Price

Quantity

Additional Notes

Priority of the item needed   Low Normal High