State Form 21303 - Purchase Order

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Requisition number
Date (month, day, year)
This page number
Total number of pages
O
PURCHASE ORDER
F
Issued by State of Indiana
Purchase order date
Required delivery date
Purchase order number
Fund / Object / Center
PUR:
Remit to:
Project number
Federal ID # of vendor
Agency number
Reporting code
Name & address
Facility
of vendor :
Ship to:
Agency phone number: (
) ____________________________________________
CONTRACT TERMS
F.O.B. DESTINATION unless otherwise stated below
Contract terms and conditions are stated on the reverse side of this document.
NOTICE: No price corrections will be permitted after issuance of this Purchase Order.
Contract terms and conditions are stated in a separate document.
Contract
QUANTITY
Line
UNIT
UNIT PRICE
AMOUNT
ARTICLE and DESCRIPTION
ORDERED
Item No.
FUNDING ENCUMBERED BY THE AUDITOR OF STATE
I certiy that there is a sufficient unencumbered balance in the above account to cover the amount of this
order, and that funds have been set aside for payment thereof.
Authorized signature, Auditor of State
Date signed (month, day, year)
Issued by Procurement Division
Indiana Department of Administration
Procurement Division
402 West Washington Street, Rm W468
Indianapolis, Indiana 46204
Telephone: (317) 232-3053
State Form 21303 (R16 / 11-00)
Original to Vendor
1
RECYCLED PAPER
Approved by State Board of Accounts, 2000; Auditor of State, 2000

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