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DEPARTMENT OF NATURAL RESOURCE <br />REQUEST FOR REQUISITION/PURCHASE ORDER <br /> <br />REQUIRED FOR GOODS AND SERVICES OVER $5,000 <br />ENTIRE <br />PLEASE COMPLETE FORM <br />DNR Purchasing Contacts: <br />COMMODITIES, PRINTING & SOLE BRAND <br />Kevin Langhorn (303) 291 - 7313 Fax (303) 291 - 7107 kev in.langhorn@state.co.us <br />PCA, PEA, PIA, PKA, PJA <br />(Services & Contracts) <br />Maggie Van Cleef (303) 866 - 4188 Fax (303) 866 - 5575 maggie.vancleef@state.co.us <br />PAA, PDA, PHA, PBA <br />(Services & Contracts) <br />Jim Sharp (303) 866 - 2532 Fax (303) 866 - 5575 jim.sharp@state.co. us <br /> <br />ARTICLES AND/OR SERVICES AS REQUESTED PER SPECIFICATIONS <br />QUANIT UNIT COMPLETE DESCRIPTION OF ITEM OR SERVICE UNIT AMOUNT <br />Y (If more than 4 lines E - mail description to Purchasing) COST <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />FUND AGENCY ORG APP PROG OBJ SUB GBL PROJECT CODE <br />UNIT CODE CODE OBJ <br /> <br /> <br /> <br /> <br /> <br />Authorized Signature: _________________________________ <br />Print Name: _________________________________ Date:_______________ <br /> <br />if different <br />BILL TO: ( Name & Address than <br />SHIP TO: ( NAME AND ADDRESS) <br /> Ship to) <br /> <br />CONTACT PERSON: State Pays Shipping (check one): Yes No <br /> Check one if Applies: <br />Sole Brand Sole Source <br /> <br />PHONE: <br /> Goods Delivery Date: <br />FAX: Services to Begin: <br />Service to End: <br />Suggested Vendor PO Mailing Address Payment Remit Vendor Number <br />Name Address <br /> <br />Phone: Fax: Contact: <br />PURCHASING USE ONLY <br />DOC ID# AGEN CY _P A _ NUMBER PRICE AGREEMENT # <br /> <br /> <br />Received by Purchasing:_______________________ <br />