Form Pss-02.2 - Special Order Form - Paperclips Etc.

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This Form May Be Saved With the Acrobat Reader or Through Your Web Browser
 
PAPERCLIPS Etc.
SPECIAL Orders Form
 
 
This form is used to order supplies that are not readily available in the DOE HQ self‐service supply stores or for items 
that require approval by Office Management. All supplies ordered MUST be used for Official Government Business only. 
 
 
Requestor’s Name: ___________________________________________________ 
Date: __________________ 
 
Phone Number: __________________   
DOE ID Badge No.: ________________________________________ 
 
Catalog Name: ______________________________________________________ 
Org Code: ______________ 
 
 
Item Number 
Page # 
Item Description 
Quantity 
Store Use Only 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
ALL printed names (legible), signatures and dates are required before your Special order is processed. 
 
 
Requestor’s Signature:  
Date: 
 
 
Office Director’s Printed Name: __________________________________________ 
 
 
Date: ________________ 
Signature: ___________________________________________________________ 
 
 
Budget Officer’s Printed Name: __________________________________________ 
 
 
Date: ________________ 
Signature: ___________________________________________________________ 
 
 
Program’s Resource Manager’s Printed Name: ______________________________ 
 
 
Date: ________________ 
Signature: ___________________________________________________________ 
 
ALL SPECIAL ORDERS ARE SUBJECT TO FULL PAYMENT OR A RESTOCKING FEE WHEN ITEMS ORDERED ARE RETURNED TO 
THE SUPPLIER DUE TO THE CUSTOMER NOT PICKING UP THE ITEM(S) WITHIN FIVE DAYS OF RECEIPT BY THE STORE 
PERSONNEL OR THE CUSTOMER’S DECISION TO RETURN THE ITEM(S). 
 
Order Received by: Printed Name: __________________________________________________________________ 
 
Signature: ______________________________________________________ 
 
Date: _________________ 
 
PSS‐02.2  (March 7, 2011)     Replaces PSS‐02.1 
 

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