State Form 21303 - Purchase Order Page 4

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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 number
Purchase order date
Required delivery date
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
ARTICLE and DESCRIPTION
UNIT
UNIT PRICE
AMOUNT
ORDERED
Item No.
RECORD OF PARTIAL PAYMENTS (Use reverse side if insufficient space is provided here)
CONTROL NO.
AMT. LIQUIDATED
CONTROL NO.
AMT. LIQUIDATED
AMT. PAID
AMT. PAID
BALANCE
BALANCE
State Form 21303 (R16 / 11-00)
4
Requesting agency record copy
RECYCLED PAPER
Approved by State Board of Accounts, 2000; Auditor of State, 2000

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