Form Gen 727b - County Forms Order

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
SUBMIT
BILL TO:
SHIP TO:
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Reset Form
COUNTY FORMS ORDER
(Instructions on Reverse)
From e-mail:
________________________
AGENCY
AGENCY, OFFICE OR SECTION
__
TO: CDSS Warehouse, 3705 Seaport Blvd #140, West Sacramento, CA 95691
PERSON TO CONTACT
DATE
ADDRESS
STREET ADDRESS AND ROOM NUMBER
COUNTY CODE
FOR:
TELEPHONE NUMBER
CITY
STATE
ZIP
CITY
STATE
ZIP
AUTHORIZING SIGNATURE
(
)
L
FORM CATALOG
PRICE
PRICE
TYPE OF ORDER
TITLE OR CATALOG DESCRIPTION
QUANTITY
UNIT OF
I
NUMBER
PER
PER
PROCESS
■ ■
WANTED
ISSUE
UNIT OF
FORM
CODE
N
REGULAR
ISSUE
ORDER
(Over)
E
PREFIX
NUMBER
SUFFIX
■ ■
EMERGENCY
1
DATE RECEIVED
2
FILLED BY:
DATE:
PACKED BY:
DATE:
3
PRICES
WEIGHT:
4
VIA
B/L
DATE:
BY:
5
REMARKS
6
7
8
9
10
11
TOTAL
ADJUSTED
ORDER:
$
ORDER:
$
GEN 727-B (7/12)

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