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J <br />Oregon Department tate ands <br />775 Summer St. NE. • Suite 100 <br />Salem, OR 97301-1279 <br />www.oregonstatelands.us <br />. All"I _kill <br />Questions? Call Purchasing C) (503)-986-5200 <br />E-mail purchasing@dsl.state.or.us <br />Vendor <br />Ship to- <br />~j <br />DEPARTMENT OF STATE LANDS <br />775 SUMMER STREET NE STE 100 <br />C ne <br />e <br />C C <br />c <br />l <br />- <br />- <br />, <br />_ <br />SALEM OR 97301 <br />1279 <br />- <br />y <br />C19 C_ 541f_ L40D <br />Customer Account # <br />Item(s) quested (please be specific, i.e., stock number, <br />Quantity <br />Unit Price <br />Extended Price <br />complete name of item, size, style, color, etc.) <br />'TC /l Y~ <br />U <br />pnci~ <br />104L2a9 319 <br />b <br />1-i Ica, <br />Estimated Delivery Date- <br />TOTAL <br />- <br />justification <br />0410 <br />531--gi33Z- 61 Sb2- q <br />Requested by <br />Date <br />( <br />Section <br />PCA (Cost Co <br />e) <br />Go 00C-1 <br />/ L1 <br />-826/ 201I <br />Approved by <br />Title <br />Date <br />0 <br />412 <br />o <br />I is item on a price agreem t? ❑ yes ❑ no BPDAS # <br />Has this order been placed verbally? ❑ yes ❑ no By whom? <br />Does the vendor require a copy of the purchase order? ❑ yes ❑ no <br />Order received by whom? Order complete? ❑ yes <br />❑ no Date <br />Date <br />PLEASE ROUTE THE TOP 3 COPIES OF THIS FORM TO THE PURCHASING AGENT. <br />FISCAL OFFICE USE ONLY: <br />❑ <br />Emailed order <br />Web purchase? ❑ yes ❑ no <br />❑ <br />Phoned in <br />❑ VISA charge <br />❑ <br />Faxed in <br />❑ Invoice to follow <br />❑ <br />Mailed in <br />Copies: White-Vendor Canary-Purchasing Agent Pink-Accounts Payable Goldenrod-Originator <br />June 2009/1M <br />